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Section 11.05 Appendix E - WVHA HealthCard Assessment Form

Rev. 6/17/2021

WVHA HealthCard Assessment Form

Application Date*

Screened by THND Representative:__________________

Instructions:

Please complete this form in its entirety. This form must be completed by all applicants over 18, including legal spouses who are not applying. Failure to provide separate WVHA HealthCard Assessment Forms will result in a Pended application.

Section 1: General Information

Last Name*

First Name*

DOB

Clinic

How did you hear about the WVHA HealthCard Program? Check one of the following boxes:

Explain Other

Section 2: Insurance Information

2.1 Do you have any Medical Insurance?

Yes

Indicate Carrier and ID#

2.2 Are you eligible for COBRA Benefits from a current employer?

Yes

2.3 Do you have Medicare A or B?

Yes

Indicate which coverage you are enrolled in and the effective date

2.4 Do you receive healthcare assistance or aid other than WVHA?

Yes

Indicate the assistance and/or aid you receive and effective date.

2.5 If you are seeking services for an injury, is your injury due to a work related or auto accident?

Yes

Please describe

2.6 Proof of Medicaid application or denial is required. Please include this with your submission.

Section 3: Family Size

3.1 Marital Status

3.2 Do you have dependent children living in the household?

Yes

Number of children

Section 4: Identification

4.1 Do you have a Driver License or other Government ID?

Yes

Please provide a copy of ID

4.2 Two (2) forms of ID are required, one (1) must be a picture ID. Please check any other proof of identification provided other than a Driver License.

Non-Picture ID:

Social Security Card

Birth Certificate

Official Document w/ Name Address and SS#

Picture ID:

Section 5: Residency

5.1 Do you own the house where you live?

Yes

Please provide current year Property Tax Bill.

5.2 Do you rent?

Yes

Please provide a copy of current Lease Contract or Verification of Rent Form.

5.3 Do you live in someone else's house?

Yes

Please provide Verification of Support Form.

5.4 Do you consider yourself homeless?

Yes

Please provide Homeless Verification Form.

5.5 All proof of residency documents must show a street address within the WVHA Tax District and must be for the past immediate 3 months. Two (2) forms of residency are required, unless you are a homeless applicant. Homeless applicants only need to submit the Homeless Verification Form.

Please check the box for the proof of residency provided:

Utility Bills (Electric, Water, etc.)

Vehicle Registration in the applicant or spouse's name

Proof children are registered in West Volusia School

Mail received during the most recent three (3) months.

Mortgage Payment

Section 6: Financial Information

6.1 Have you been employed in the last 8 weeks?

Yes

Complete the Employer information and provide 8 weeks of paystubs or DCF Verification of Employment/Loss of Income Form.

Employer Name

Pay Frequency
Hourly
Daily
Weekly
Biweekly
Monthly

Business Address
Street Address City State Zip

6.2: Have you lost your job in the last 8 weeks?
Yes
No

Please provide a DCF Verification of Employment/Loss of Income Form.

6.3: Are you self-employed?
Yes
No

Please provide most recent tax return (complete with all schedules and forms) or self-employment quarterly statement.

6.4 Are you receiving Unemployment or Worker's Comp benefits?
Yes
No

Please provide Unemployment or Worker's Comp Documents.

6.5 Is someone else supporting you?
Yes
No

Please provide a notarized Verification of Support Form.

6.6 Do you receive Veteran or Military Benefits?
Yes
No

Please provide benefits paperwork.

6.7 Do you receive any settlements?
Yes
No

Please provide settlement paperwork.

6.8 Do you receive Food Stamps?
Yes
No

Please provide supporting documentation from Florida DCF along with approved amount.

6.9 Are you receiving any monthly Pension or Retirement Income?
Yes
No

Please provide documentation showing the amount you receive.

6.10 Do you receive any Alimony or Child Support Income?
Yes
No

Please provide documentation showing the amount you receive.

6.11 Do you receive any income from rental properties?
Yes
No

Please provide rental income amounts and rental agreement.

6.12 Do you receive Social Security Income or Disability Benefits?
Yes
No

Please provide documentation showing the amount you receive.

Section 7: List All Sources of Income for the Household

(i.e., Temporary Assistance for Needy Families, Strike Benefits, Insurance/Annuity Income, Dividend/Interest Earnings, Training Stipends, Compensation for Injury/Settlement, Gifts from Churches/family/organizations etc.) Please provide all supporting documentation for any Income listed below.

Household Member's Name

Type of Income

Employer
(or Source of Income)

Monthly Amount
(before deductions)

Do you have additional sources of Household income to list?
Yes
No

Household Member's Name

Type of Income

Employer
(or Source of Income)

Monthly Amount
(before deductions)

Do you have additional sources of Household income to list?
Yes
No

Household Member's Name

Type of Income

Employer
(or Source of Income)

Monthly Amount
(before deductions)

Do you have additional sources of Household income to list?
Yes
No

Household Member's Name

Type of Income

Employer
(or Source of Income)

Monthly Amount
(before deductions)

Do you have additional sources of Household income to list?
Yes
No

Household Member's Name

Type of Income

Employer
(or Source of Income)

Monthly Amount
(before deductions)

Section 8: Assets

8.1 Do you own a checking/savings account?
Yes
No

Please provide a copy of statements for all the accounts for the last 3 months.

8.2 Do you own a Business?
Yes
No

Please provide last Quarter Business Financial Statements and Bank Statements.

8.3 Do you own property(ies) in other counties/states or country (including rental properties you own)?
Yes
No

Please list all the properties you own below, including lots, and provide any outstanding mortgage documentation outside of your permanent residence.

Property Address