Form Dhs-2 - Application For Assistance - Rhode Island Department Of Human Services Page 29
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38DHS-2
Rev: 01-16
Is there a child or adult applying for Medicaid covered by a
37
Yes
health insurance, Long-Term Care insurance, dental insurance
program or HMO other than Medicare, Medicaid, RIteCare or
No
RIteShare?
EXAMPLES:
BlueCross/Blue Shield
United HealthCare of New England
Delta Dental
BlueChip
Neighborhood Health Plan of RI
BCBS Dental
If yes, complete the boxes below.
I N S U
Policy Holder’s name
Health and/ or Dental
Type of
Family
[ ]
If premium paid by you
Last Name
First Name
Initial
Insurance Name
Coverage
Individual [ ]
Amount/How Often
$_______per_______
Policy Number
Group Number
Is insurance
If yes, name of employer providing
Code
Type
Req
provided by employer?
insurance:
Yes [ ] No [ ]
Please list below person(s) covered by this policy.
Last Name
First Name
Initial
Relation
Individual’s Policy Number
Begin Date
End Date
___/___/___
___/___/___
___/___/___
___/___/___
___/___/___
___/___/___
___/___/___
___/___/___
Policy Holder’s name
Health and/ or Dental
Type of
Family
[ ]
If premium paid by you
Last Name
First Name
Initial
Insurance Name
Coverage
Individual [ ]
Amount/How Often
$_______per_______
Policy Number
Group Number
Is insurance
If yes, name of employer providing
Code
Type
Req
provided by employer?
insurance:
Yes [ ] No [ ]
Please list below person(s) covered by this policy.
Last Name
First Name
Initial
Relation
Individual’s Policy Number
Begin Date
End Date
___/___/___
___/___/___
___/___/___
___/___/___
___/___/___
___/___/___
___/___/___
___/___/___
Do you, your spouse, or anyone in the household have any unpaid
Yes
38
No
medical bills?
Yes
If yes, did you have any medical coverage when the bills were incurred?
No
If you have any unpaid medical bills, complete the boxes below about each person who received medical treatment.
M E D X
Last Name
First Name
Initial
Date of Service
Who do you owe?
Amount Owed
_____/_____/_____
$ ___________
_____/_____/_____
$ ___________
_____/_____/_____
$ ___________
Please read the Rigths and Responsibilities on pages 27 - 30 and sign on page 30.
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