| Patient Information |
Fields Marked * are Required:
* Must provide proof of residence (example – utility bill, lease agreement) |
| * Application Date: |
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* Name: |
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Maiden Name: |
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* Address: |
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* City, State: |
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*Zip: |
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*County of Residence: |
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Do you: |
Own
Rent |
| Phone Number: |
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| Email Address: |
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| * Social Security No.: |
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* Date
of Birth:
(mm/dd/yy) |
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| * Place of Birth: |
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| Sex: |
Male
Female |
| Marital Status: |
Single
Married (legal or common law)
Divorced
Widowed |
| Have you ever received services through JPS Health Network?: |
Yes
No |
| * Is the patient pregnant?: |
Yes
No |
| Household Information |
Please list below every person living in the house with the patient and complete all requested information for each household member.
*Copies of identification documents such as drivers license or birth certificate, and Social Security cards must be provided for each household member. |
| 1st Household Member |
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Name: |
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Relationship to Patient: |
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Date of Birth: |
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Social Security No.: |
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Employed?: |
Yes
No |
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US Citizen/Permanent Resident?: |
Yes
No |
| 2nd Household Member |
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Name: |
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Relationship to Patient: |
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Date of Birth: |
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Social Security No.: |
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Employed?: |
Yes
No |
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US Citizen/Permanent Resident?: |
Yes
No |
| 3rd Household Member |
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Name: |
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Relationship to Patient: |
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Date of Birth: |
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Social Security No.: |
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Employed?: |
Yes
No |
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US Citizen/Permanent Resident?: |
Yes
No |
| 4th Household Member |
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Name: |
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Relationship to Patient: |
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Date of Birth: |
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Social Security No.: |
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Employed?: |
Yes
No |
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US Citizen/Permanent Resident?: |
Yes
No |
| Income & Asset Information – Required for each adult member of household |
*Must provide proof of income and assets (example – 4 current check stubs, and bank statements, most recent tax returns; award letters)
Income and asset information is not required from parents of an adult child who is applying for JPS Connection if parents are not applying for JPS Connection coverage |
| 1st Household Member |
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Name: |
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Monthly Income |
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Name of Employer: |
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Employer Address: |
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Employer City, State: |
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Zip: |
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County of Residence: |
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Employer Phone No.: |
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Covered by employer health insurance?: |
Yes
No
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| Employment Income – monthly ($): |
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| Self employed income ($): |
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| Unemployment/Worker’s Compensation ($): |
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| Child Support/Alimony ($): |
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| Pensions/Retirement ($): |
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| Social Security (SSI) (Disability) ($): |
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| VA Benefits ($): |
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| Last income tax return filed: |
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| Gross taxable wages per tax return ($): |
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Value of Assets |
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Property – value of home, land, buildings ($): |
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Automobile – Yr/Make/Model ($): |
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Bank Name(s): |
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Bank Account Balances ($): |
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IRA/other investments ($): |
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Major Expenses – Monthly |
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Mortgage Payments/Rent ($): |
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Child Support/Alimony ($): |
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Automobile payment (if applicable) ($): |
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Other Loan Payments ($): |
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| 2nd Household Member |
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Name: |
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Monthly Income |
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Name of Employer: |
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Employer Address: |
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Employer City, State: |
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Zip: |
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County of Residence: |
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Employer Phone No.: |
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Covered by employer health insurance?: |
Yes
No
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| Employment Income – monthly ($): |
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| Self employed income ($): |
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| Unemployment/Worker’s Compensation ($): |
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| Child Support/Alimony ($): |
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| Pensions/Retirement ($): |
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| Social Security (SSI) (Disability) ($): |
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| VA Benefits ($): |
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| Last income tax return filed: |
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| Gross taxable wages per tax return ($): |
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Value of Assets |
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Property – value of home, land, buildings ($): |
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Automobile – Yr/Make/Model ($): |
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Bank Name(s): |
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Bank Account Balances ($): |
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IRA/other investments ($): |
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Major Expenses – Monthly |
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Mortgage Payments/Rent ($): |
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Child Support/Alimony ($): |
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Automobile payment (if applicable) ($): |
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Other Loan Payments ($): |
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| 3rd Household Member |
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Name: |
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Monthly Income |
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Name of Employer: |
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Employer Address: |
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Employer City, State: |
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Zip: |
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County of Residence: |
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Employer Phone No.: |
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Covered by employer health insurance?: |
Yes
No
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| Employment Income – monthly ($): |
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| Self employed income ($): |
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| Unemployment/Worker’s Compensation ($): |
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| Child Support/Alimony ($): |
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| Pensions/Retirement ($): |
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| Social Security (SSI) (Disability) ($): |
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| VA Benefits ($): |
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| Last income tax return filed: |
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| Gross taxable wages per tax return ($): |
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Value of Assets |
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Property – value of home, land, buildings ($): |
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Automobile – Yr/Make/Model ($): |
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Bank Name(s): |
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Bank Account Balances ($): |
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IRA/other investments ($): |
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Major Expenses – Monthly |
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Mortgage Payments/Rent ($): |
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Child Support/Alimony ($): |
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Automobile payment (if applicable) ($): |
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Other Loan Payments ($): |
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"I understand that anyone who knowingly lies or misrepresents the truth or arranges for someone to knowingly lie or misrepresent the truth in the completion of this application is committing a crime which can be punished under Federal law and/or State law. Everything on this application is the truth as best I know it."
If at any time false information is discovered, penalties will include, but are not limited to, loss of my benefits and the inability to reapply for the JPS Connection Program for no less than a period of ninety (90) days.
I authorize JPS Health Network to run a credit bureau report for the purpose of making a preliminary determination of whether I meet the eligibility requirements for the JPS Connection Indigent Healthcare Program. I also understand that any approval will be conditional based on the information reviewed in my credit report.
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