Screening Question Comparisons
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1
UQID
Source
RowColQuestionAnswer hint
Perceived Purpose
2
AN 1AN1Today's DateAP
3
AN 2aAN2aLast NameID
4
AN 2bAN2bFirst NameID
5
AN 2cAN2cMIID
6
AN 2eAN2eSSNIf no SSN, write "None"ID
7
AN 2dAN2dDOBmm/dd/yyyyID
8
AN 3aAN3aEmail AddressCI
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AN 3bAN3bDo you have transportation?YES; NOSF
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AN 4aAN4aCurrent AddressCI
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AN 4bAN4bApt #CI
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AN 4cAN4cCityCI
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AN 4dAN4dStateCI
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AN 4eAN4eZipCI
15
AN 5aAN5a
How long have you lived in the greater Richmond area?
___ Years ___ MonthsEQ
16
AN 5bAN5b
Are you traveling in the U.S. on a temporary Visa?
YES; NOES
17
AN 5cAN5cDo you:
(circle one) Own; Rent; Live with family or friends; Live in shelter; Other
DI
18
AN 5dAN5dCity/County of ResidenceEQ
19
AN 6aAN6aHome Phone(Area Code First)CI
20
AN 6bAN6bCell Phone(Area Code First)CI
21
AN 6cAN6cWhat is your primary language?English, Spanish, Arabic, Other______SF, DI
22
AN 6dAN6dDo you have access to an interpreter?YES; NO; N/ASF
23
AN 7aAN7aWould you say that you are:
American Indian/Alaskan Native, Asian, Black or African-American, Native Hawaiian/Pacific Islander, White, Other________
DI
24
AN 7bAN7bWhat is your ethnicity?
Hispanic or Latino____; Non-Hispanic or Latino
DI
25
AN 8aAN8aAre you
Married Single Divorced Separated Widowed
DI, HH
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AN 8bAN8bWhat is your highest level of education?DI
27
AN 8cAN8cPatient ID #ID
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AN 8dAN8dAre you:Male FemaleDI
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AN 8eAN8eTG:MTF FTMDI
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AN 9aAN9aEmergency Contact Name/Relationship:CI
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AN 9bAN9bEmergency Contact Number(area code first)CI
32
AN 10aAN10aHousehold Information:
Please list the names and relationships of the patient's family unit living in the house.
HH
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AN 10bAN10bName(ex. John Doe)HH
34
AN 10cAN10cDOB/Age(mm//dd/yyyy)HH
35
AN 10dAN10dRelationship to Patient(ex. Self, son, wife)HH
36
AN 10eAN10eSSN(If no SSN, write "None")HH
37
AN 10fAN10fHead of Household(as stated on tax return)HH
38
AN 10gAN10gFamily Members in HouseHH
39
AN 11aAN11aDid you file taxes in the last year?YES NOPI
40
AN 11bAN11b
If NO, did someone else claim you on their return?
YES NOHH
41
AN 12AN12
If the patient did file taxes last year, and claims a person on their taxes who does not live in their household, please list those persons here:
HH
42
AN 13AN13Employment and Insurance Information:
Please list the patient's work status and insurance information below
EI
43
AN 14aAN14aWhat is you employment status?
Full-time, Part-time, Seasonal, Disabled, Retired, Student, Dependent, Unemployed
EI
44
AN 14bAN14b
What is your spouse's employment status?
N/A Full-time, Part-time, Seasonal, Disabled, Retired, Student, Dependent, Unemployed
EI
45
AN 15aAN15aIf you are unemployed, for how long?N/A Yrs:_____ Mos:______EI, DI
46
AN 15bAN15bIf spouse is unemployed, for how long?N/A Yrs:_____ Mos:______EI, DI
47
AN 16aAN16aAre you a veteran of the United States?YES NODI, ES
48
AN 16bAN16bIf yes, have you applied for benefits?YES NOES
49
AN 16cAN16cIf yes, are you eligible for benefits?YES NOES
50
AN 17aAN17aWhat is your place of employment?N/AEI
51
AN 17bAN17bTime Employed ThereYrs:____EI
52
AN 17cAN17cWork Phone(with area code)EI
53
AN 18aAN18a
What is your spouse's place of employment?
N/AEI
54
AN 18bAN18bTime Employed ThereYrs:____EI
55
AN 18cAN18cWork Phone(with area code)EI
56
AN 19aAN19aDo you have medical insurance?YES NOIC, EQ
57
AN 19bAN19bIf YES, what type?Private, Medicaid, Medicare, VeteransIC, EQ
58
AN 19cAN19cDo you have prescription drug coverage?YES NOIC
59
AN 19dAN19dDo you have a VCC Card?YES NOIC
60
AN 20AN20
Have you ever applied for Social Security Disability?
YES NOIC
61
AN 20AN20If YES, date effective:IC
62
AN 20aAN20aHave you ever applied for Medicaid?YES NOIC
63
AN 20bAN20bIf YES, date effective:IC
64
AN 21AN21
When and where did you last receive healthcare services?
MI
65
AN 22aAN22a
Is your healthcare the result of an accident?
YESIC
66
AN 22bAN22bIf YES, was the accident work-related?YES NOIC
67
AN 23aAN23a
Do you receive either of the following? If YES, please circle:
SNAP Benefits General ReliefHI
68
AN 23bAN23bIncome Information
Please list the amount of income, before taxes, earned by ALL PERSONS in the faimly unit. Include the following types of income: wages/salary/self-employment, child support/alimony, interest/dividends, disability benefits, reitrement benefits, Social Security Income, Unemployment benefits, and any other type of income. Do not include income fro loans.
HI
69
AN 23cAN23cPerson Receiving IncomeHI
70
AN 23dAN23dEmployer's Name or Source of IncomeHI
71
AN 23eAN23eHow Often Do You Receive This?HI
72
AN 23fAN23fAmountHI
73
AN 23gAN23gTotal Monthly Income ReceivedHI
74
AN 24aAN24a
If no income is received, how do you provide food and shelter for yourself/family?
HI
75
AN 24bAN24b
If no income is received, how do you provide for other daily living expenses (i.e., help with bills, medications, etc.) for yourself/family?
HI
76
AN 25aAN25aProof of Income Provided:
Please check which type of proof has been provided to verify income.
PI
77
AN 25bAN25bPay Stubs # Provided:PI
78
AN 25cAN25c1040 Plus Schedules/Year:Schedule C if self-employedPI
79
AN 25dAN25dLetter from EmployerOn letterheadPI
80
AN 25eAN25eLetter from Social Services AgencyPI
81
AN 25fAN25fUnemployment Award LetterPI
82
AN 25gAN25gFood, Shelter and Support LetterNOTARIZEDPI
83
AN 25hAN25hFood Stamp Award LetterPI
84
AN 26aAN26aPatient Signature:
Please have the patient sign the following certification statement.
PC
85
AN 26bAN26b
Patient: I CERTIFY that this information is true and accurate to the best of my knowledge.
I understand that the information is subject to verification. I understand that if my financial situation changes or I obtain health insurance, my eligibility status will need to be re-evaluated. I understand it is my responsibility to notify THE CLINIC f any changes in my financial situation. I authorize the release of my financial records (including Social Security Number) to RX Partnership, pharmaceutical companies and Access Now and/or their agents to determine my eligibility for financial assistance for medicines and verification during routine audits. This review is a check on eligibility only. It is not a guarantee that I will receive benefits from any source, and THE CLINIC offers no such guarantees. I understand that falsification of information submitted will jeopardize my consideration for the program.
PC
86
AN 26cAN26cSignature of Patient:PC
87
AN 26dAN26dDate:PC
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AN 27AN27For Clinic Use OnlyCU
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AN 28aAN28aMonthly Gross IncomeCU, EQ
90
AN 28bAN28bAnnual Gross IncomeProjectedCU, EQ
91
AN 28cAN28cPoverty Level0-138% ( ) 139-200% ( )
CU, EQ, FPL
92
AN 29aAN29aDate Reviewed by Screener:CU
93
AN 29bAN29b
I certify that based upon the information provided, the individual is eligible for Access Now Services.
(Name of Screener)CU
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AN 29cAN29c
Identify the reason for Eligibility for Access Now Services (Check all statements that apply):
___Individual is not eligible to enroll in and/or recieve Health Exchange financial assistance.
___Individual/family has been exempted from participating in the Health Exchange
___Individual/family has applied for exemption but not yet received determination
___The individual's income is below 139% of the federal poverty level
___The Clinic Medical Director determined it is in the best medical interest of the patient to receive healthcare services through the Safety Net and Access Now.
CU, EQ
95
DP 1DP1DateAP
96
DP 2DP2
Please let us know what medical service(s) you are seeking:
___Medical Care
___Dental Services
___Vision Care
___Behavioral Health Treatment
___Mental Health
___Substance Abuse
___Voter Registration Info.
___School or Work Physical
___TB Test Only
MI, SF
97
DP 3aDP3aLast NameID
98
DP 3bDP3bFirst NameID
99
DP 3cDP3cMIID
100
DP 4aDP4aDOBID
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Base Questions Data
Identity Questions
Contact Info Questions
Demographic Questions
Household Size and Structure Questions
Employment Questions
Health Insurance Coverage Questions
Household Income, Assets & Liabilities Questions
Proof of Income Document Questions
Direct Eligibility Questions
Medical Questions
Service Facilitation Questions
Patient Consent
Application Tracking