Health Coverage Form El niño’s seguro de salud Parent/Guardian of:
DOB:
Padre/Guardian de:
At the time of enrollment, my child/En el momento de la inscripción, mi hijo: ☐ Has Medicaid, CHIP, or other Insurance coverage (copy of card provided) Tiene Medicaid, CHIP, u otra cobertura de Seguro (copia de la tarjeta proporcionada) ☐ Does not have Medicaid, CHIP, or other Insurance coverage (check one below) No tiene Medicaid (marque uno abajo) You have indicated that your child does not have medical insurance. Please mark one of the following En el momento de inscripción, ha indicado que su hijo no tiene seguro medico. Por favor marque uno de lo siguiente: ☐ I am in the process of re-applying for Medicaid or other Health coverage. I will provide Head Start with a copy of my Insurance card when it is received. Estoy en el proceso de aplicar por segunda vez, para Medicaid u otra cobertura de salud. Le proveeré a Head Start una copia cuando lo recibe. ☐ My child is not eligible for Medicaid or other Health coverage at this time. I have been given information on how to apply for Title V funding. Mi hijo no es elegible para Medicaid u otra cobertura de salud en este tiempo. Me han dado información sobre como ser aplicación para financiación en el Title V. Title V Clay, Montague, Wichita County Condado de Clay, Montague, Wichita Community Health Care Center 200 Martin Luther King Jr. Blvd. Wichita Falls, TX 76307 (940) 766-6306
Title V Cooke County Condado de Cooke Health Services of North Texas 4210 Mesa drive Denton, TX 76207 (940) 381-1501
☐ Information on how to apply for Medicaid/CHIP has been given to me at this time. Head Start staff is available for further assistance, if needed. Una aplicación de Medicaid/CHIP se le ha dado. Favor de llenar la aplicación y devolverlo a su oficina local de Medicaid. El personal de Head Start está listo para servirle, si lo necesita. Wichita County Condado de Wichita 1328 Oakhurst Wichita Falls, TX 76302 Phone: (940) 767-1720 Fax: (940) 720-8446
Montague County Condado de Montague 601 E. Decatur St., B Bowie, TX 76230 Phone: (940) 872-1196 Fax: (940) 872-4448
Cooke County Condado de Cooke 1714 Justice Center Blvd. Gainesville, TX 76240 Phone: (940) 665-9315 Fax: (940) 665-6754
Online: www.yourtexasbenefits.hhsc.texas.gov
Parent/Guardian Signature / Firma de Padre/Guardián
Date / Fecha
Head Start Staff Signature / Firma de Personal de Head Start
White copy: file Yellow copy: parent. Health Coverage Form ... Has Medicaid, CHIP, or other Insurance coverage (copy of card provided). Tiene Medicaid, CHIP ...
Regresa esta forma a la escuela antes del 31 de mayo. El original será guardado en el registro escolar del menor. Rev.03-09. Requerimiento de Salud Dental ...
For Office Use Only: Forward completed form to the Campus Nurse ... If "Yes", and medication needs to be administered at school, please fill out appropriate ...
If "Yes", do you have a copy for our records? ... If "Yes", please list: ... Example: death or serious illness in immediate family, major economic changes, abusive.
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Call 855.413.2432. (TTY: 800.743.3333). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 855.413.
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IUHEXG_146. Health insurance coverage from a name you trust. You can feel confident knowing that Indiana University Health Plans is an insurance provider.
for Children at Indiana University Health, one of the nation's top children's ... Federal civil rights laws and does not discriminate on the basis of race, color, ...
to this release of information by giving notice to IU Health Physicians in writing. Health Insurance Portability and Accountability (HIPAA): I acknowledge that I ...
Access to other providers and hospitals throughout Indiana that are close to home, including. Deaconess Health System. □ Free yearly check-ups, screenings ...
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Health insurance coverage from a name you trust. You can ... The benefit information provided is a brief summary, not a complete description of benefits. ... which can be used to pay for eligible medical expenses until your deductible is met.
Access to other providers and hospitals throughout Indiana that are close to home, including. Deaconess Health System. □ Free yearly check-ups, screenings ...
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I hereby consent for my child, ... In order to better serve the health needs of my child, I hereby give my permission for the transfer of ... Type of family housing: ...
Code Ann. S71-3-69 (Rev. 2000) and upon conviction be subjected to the penalties therein provided. For Placing a Claim, Call: WC 99.9723E (08/09) 1866-270- ...
The benefit information provided is a brief summary, not a complete description of benefits. For more ... Mental/Behavioral Health and Substance Abuse Disorder.
Volvió el interés de · inversores argentinos en · inmuebles de Miami - Télam · - Agencia Nacional de · Noticias. Dec 9 2016. (IMAGE 1 OF 3). (est.) monthly visits:.
IU Health Plans Gold Value. IU Health Plans In-Network Benefit: IU Health Plans covers healthcare services for physicians and hospitals that are in-network only ...
