INTAKE AND ELIGIBILITY FORM
This form is used by staff (who may or may not be case managers) to obtain and document required
information to determine a person’s eligibility to receive HIV/AIDS medical and support services under
the Mecklenburg County Transitional Grant Area (TGA).
Date of Initial Contact:
/
/
Date Intake/Eligibility Initiated:
_________________________________
Date Intake Completed
Personal/Contact Information
NAME
Soc.Sec.No.
Address
City/Township
County
State
Zip Code
Referred By
Phone (H) (
/
_________________
Case Manager Signature
a.
/
Phone
)
(W) (
Date of Birth
Race
Client provided proof of residency: Y
N
)
(Emg) (
)
Language
Client Preference for Contact (circle)
Phone
Message
Office Visit
Home
Can talk to: 1.____________________________________ 2.___________________________________
Is it O.K. to include HIV/AIDS info in day phone contact?
Y
N
Is it O.K. to include HIV/AIDS info in evening phone contact?
Y
N
Is it O.K. to include HIV/AIDS info in mail?
Y
N
Gender: M / F / Trans
Ethnicity: White / African-American / Hispanic / Native American / Asian-Pacific
Marital Status: S / M / P* / D / W
Comments:
Employed: Yes / No
Household Size:
Name of Employer:
HIV Positive? Yes / No /
AIDS Diagnosis? Yes / No
Date of Test:
/
/
Test Location:
Date of AIDS Diagnosis: /
Client Statement of Needs:
*Partner
1
/
CD4:
Date of CD4:
/
/
b.
Screening for Medicaid and Other Programs
1. Indicate the results of the Medicaid verification:
Eligible
Y/N
Date
/ /
Medicaid Cap C Program
Medicaid Cap DA Program
Medicare
Dually Eligible for Medicaid and Medicare
Medicaid HMO
2. Indicate Other Program Participation.
Eligible
Y/N
ADAP - AIDS Drug Assistance Programs
AICP - AIDS Insurance Continuation Program
North Carolina Health Choice for Children
WIC – Women, Infants and Children and
Nutrition Services
HOPWA – Housing Opportunities for People
With AIDS
Local Indigent Programs
Department of Social Services Emergency Assistance Program
Veterans Administration
Department of Social Services Food Stamps
Subsidized Child Care
Employment Securities Commission
Other
3. Insurance Information
Do you have any other health insurance?
Y
N
If no, skip to next section
Is your health insurance through your current or previous employer?
If through your previous employer, DATE Cobra coverage began:
Name of Insurance Company:
Address:
Phone: (
)
2
/
/
Group #:
Policy #:
c.
Client Financial Assessment
Income
Amount
Notes
Y/N
Unemployed
Wages or Salary:
How Long:
Name of Employer:
Address:
Tips
Self-Employment:
Name of Employer:
Address:
Social Security Benefits
Temporary Assistance to Needy Families
Program
Worker’s Compensation
Unemployment Compensation
Other insurance benefits
Trust Fund
Retirement Benefits
Assistance given by relative and/or friends
Income from rental of personal property
Other monthly assistance from welfare agencies,
public or private
Child Support and/or Alimony received
(A)
Total Annual Income
1. Name and amount of income for all adult family members 18 and over
Name
Relationship
Total Annual Income
Add __________ +_________ = ____________
A
B
Total Income
3
Amount of Income
(B)
Determine a client’s family size and gross family income on the Federal Poverty Guidelines
and locate the poverty level percent that corresponds to the client’s gross income and family
size on the Federal Poverty Guidelines.
2. Check which documentation provides proof of income and attach copies to this form:
Type of Income
Employment Income
Child Support Payments
Social Security (SSDI, OASDI)
Supplemental Security Income (SSI)
VA Benefits
Retirement Benefits
Interest income or other investment income
Other Cash Support
Documentation
____ Pay check stub for the past month,
____ Signed employer statements with dates,
____ Position and phone number or income,
____ Tax return
____ Court Order/Copy of Check
____ Social Security Award Letters
____ Statement/Award Letter
____ Statement/Award Letter
____ Award Letter/Copy Check
____ Bank Statements
____ Family and Friends
____ Other Appropriate and Related
Other
d.
Residency
YES
NO
The person is living in the state of North Carolina at the time of the
eligibility determination:
Client provided the following as proof:
A physical living address (as well as a mailing address if the two
are not the same):
The person is a resident of North Carolina
If no, the person was referred to_________________________ for
additional services.
e.
Must Be Willing To Sign All Forms and Provide Eligibility Documentation
YES
The person is willing to sign all forms and provide all appropriate
documentation to assist with the eligibility determination process in
an expeditious manner.
4
NO
Eligible ________ Y ________ N
Comments: _______________________________
________________________________
Client Signature: _________________________________
Date: ______________
Case Manager: __________________________________
Date: ______________
5