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Get and Sign Application for Disproportionate Share Hospital Program Dsh and Medicaid Kchip Screening Form 2013-2022
Eligibility determination.
Section 1: Individual Information
1.
2.
3.
4.
Today’s Date:
Patient’s Name:
Street Address:
City:
State:
Zip Code:
5. *Social Security Number:
6. Date of Birth:
8.
9. Work Phone:
10. Dates Hospital Provided Service:
11. Married/Single:
12. Name of Spouse:
13. Is the patient pregnant?
Yes No
If YES, refer the patient to DCBS for Medicaid eligibility determination
7. Patient’s Sex:
14. Is the patient a resident of Kentucky?
Yes
No
(“Resident” is defined as a...
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