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Section 11.04 Appendix D - WVHA HealthCard Application Form

Rev. 6/17/2021

WVHA HealthCard Application

Application Date*

Section 1: Applicant Information.

All members of Household may apply through same application. Please indicate all applicants in Section 2 'Members of the Household".

Last Name*

First Name*

Middle Name*

Maiden or Other

Physical Address (Where You Reside)*

Address Line 2

City*

State*

Zip Code*

County*

Is This Address Also Your Mailing Address?*

Yes

Mailing Address

Street Address Address Line 2 City State ZIP Code

Have You Lived at Current Residence More Than 3 Months?*

Yes

How long have you lived at residence?

Temp/Perm

Temporary

Permanent

Rent/Own/Other

Rent

Own

Other

Explain Other

Previous address if less than 3 months

Street Address Address Line 2 City State ZIP Code

Date of Birth*

Sex*

Male

Female

Daytime Telephone*

Evening Telephone

Section 2: Members of the Household

List legal spouse, dependent children, stepchildren, adopted children, unrelated minor with proof of custody, children over 18 up to 24 years old that are full time students and claimed on parent's income taxes as dependents.

Add your first Household Member

Name

Relationship

SS#

DOB

Applying for Health Card?

Yes

Are there additional Household Members to add?

Yes

Household Member 2

Name

Relationship

SS#

DOB

Applying for a Health Card?

Yes

Are there additional Household Members to add?

Yes

Household Member 3

Name

Relationship

SS#

DOB

Applying for a Health Card?

Yes

Are there additional Household Members to add?

Yes

Household Member 4

Name

Relationship

SS#

DOB

Applying for a Health Card?

Yes

Are there additional Household Members to add?

Yes

Household Member 5

Name

Relationship

SS#

DOB

Applying for a Health Card?

Yes

Are there additional Household Members to add?

Yes

Household Member 6

Name

Relationship

SS#

DOB

Applying for a Health Card?

Yes

Are there additional Household Members to add?

Yes

Household Member 7

Name

Relationship

SS#

DOB

Applying for a Health Card?

Yes

Are there additional Household Members to add?

Yes

Household Member 8

Name

Relationship

SS#

DOB

Applying for a Health Card?

Yes

Section 3: Authorization to Release Medical and Individually Identifiable Protected Health Information (PHI).

All Applicants over 18 must sign below or application will be Pended.

I on my behalf and behalf of any applying family member under the age of 18, do hereby authorize West Volusia Hospital Authority (WVHA), WVHA miCARE Clinics and any of their successors and/or assigns and any of their independent sub-contractors and participating providers, to release and exchange any and all data, records and information related to medical records and individually identifiable protected health information (PHI) in their respective capacities as covered entities under HIPPA, and as allowable under federal and state laws, including but not limited to the data, records, and information necessary to provide care and/or administer the WVHA Indigent HealthCard Program.
I hereby waive, relinquish, and release the organizations referenced above, who have been granted the authority to release information to each other and otherwise, from any and all claims arising out of my authorization to release this information in accordance with the terms of this document.
A photocopy of this Authorization is considered as valid as the original. You are entitled to make and return a photocopy of the authorization. The authorization referenced above in regard to medical records shall remain in effect indefinitely unless properly terminated by written notice.
I understand that if I or any of my family members receive benefits under WVHA HealthCard to treat an injury or medical condition that was caused by a third party, then WVHA claims a right to be subrogated to the rights of the beneficiary to recover damages from that third party (to be subrogated will mean that WVHA must be reimbursed for the benefits it has paid if the WVHA HealthCard member of his/her family recovers any damages or receives payments from that third party or an insurer on account of that injury or medical condition).

I certify that the information given by me for the purpose of qualifying for the WVHA HealthCard Program is true and correct. I understand it is my responsibility to report to the WVHA Enrollment Certifying Agent (The House Next Door) within fifteen (15) Days of any change in my residence and/or mailing address and if my household income goes above the 150% gross income limit for my household size. I understand and hereby authorize WVHA and its agents to conduct such investigation, including, but not limited to obtaining my credit report, as necessary to verify the accuracy of the information provided. I understand that any misrepresentation by evidence of submission or omission may result in my termination from the WVHA HealthCard Program.

Signature 1: _____________________________________________________ Date:______________________

Signature 2: _____________________________________________________ Date:______________________

Signature: 3._____________________________________________________ Date:______________________

Signature: 4._____________________________________________________ Date:______________________

Signature: 5. _____________________________________________________ Date:______________________

Signature: 6. _____________________________________________________ Date:______________________

Signature: 7. _____________________________________________________ Date:______________________

Signature: 8.______________________________________________________ Date:______________________

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