Eligibility Screening Form - Heart City Health

Affordable Care Act/Medicaid/Medicare

Date*

Name*

First Last

Name

First Last

Name

First Last

Cell phone number*

Home phone number*

Best time to contact you?*

Have you recently applied for Medicaid or Medicare?*

When did you apply?

Do you have a Marketplace account (healthcare.gov)?*

Number of people in household?*

Number of adults in household?*

Number of children in household?*

People on Medicaid (if any)?

Are you currently employed?*

If not currently employed, what is the primary source of income?

How did you hear about Heart City Health Center?*

Check one*

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