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IBCCP Eligibility Determination

Shaded area is for IBCCP office use only

Client Information

Client Status

New Client

Established Client

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Cornerstone #

Registration Date

Annual Date

Date

Cornerstone #

Name(Required)

Previous Last Name(Required)

Age(Required)

Birth Date

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone

Day Phone

Medical / Insurance Coverage

Medical / Insurance Coverage: Check all that apply.

Medicare Part B – Not eligible for IBCCP

Medicaid ID number

I DO NOT have insurance

I have Insurance

Medicaid ID number

Name of Carrier

Are you covered under a parent or spouse insurance?

No

Yes

If yes, Insurer Name

Does insurance pay for Pap tests?

No

Yes

Does insurance pay for Mammograms?

No

Yes

Do you have a deductible that must be met before diagnostic procedures are covered?

No

Yes

Please provide a copy of the front and back of your insurance card.

Employment, Marital Status & Education

Employment Status

Employed full-time (35+ hours weekly) (EFT)

Employed part-time (EPT)

Not in the labor force (NLF)

Seasonal/Migrant Farm Worker (SMF)

Self-employed (SE)

Temporary Worker (TW)

Unemployed (UNE)

Marital Status

Never Married (01)

Married (02)

Other

Marital Status – Other

Years of Education Completed

Education

Unknown (E099)

Income Determination

Income determination: (circle one)

Total income before taxes (If married - total combined income before taxes).

Income Frequency

per month

per year

Number of people supported by this income

Office Use Only: Income Status

Income status for number in household

At or below 250% of federal poverty level

Above 250% of federal poverty level

Demographic Information

Are you of Hispanic or Latino origin?

Yes (01)

No (00)

Preferred language for delivery of service

English (E)

Spanish (S)

Other (O)

Preferred language – Other

What races do you consider yourself? Mark ALL that apply.

White

Black or African American

Asian

Chinese

Indian

Japanese

Vietnamese

Korean

Filipino

Other

Native Hawaiian/Other Pacific Islanders

American Indian/Alaskan Native

Race – Other

Program Referral

How did you hear about this program?

Poster (PO)

Newspaper (ME)

Flier (FL)

Radio (ME)

Brochure (BR)

Television (ME)

Community Navigator (C)

Website (Agency/State) (WB)

Community Event (CE)

Physician or Health Care Provider (P)

Other (OTH)

Who

Phone #

Other (OTH), Specify

Barriers

None

Transportation

Child/family Care

Work schedule

Understanding medical needs

Special needs

Financial

Need Interpreter

Travel Distance

Making appointments

Other

Barriers – Other

Appointment Preferences

Preferred Healthcare Provider

Day of the week

Monday

Tuesday

Wednesday

Thursday

Friday

Time of day

Early morning

Mid morning

Early afternoon

Late afternoon

Applicant Certification

I certify that the information I have provided on this application form is the truth to the best of my knowledge.

Signature(Required)

Your Name
Your Name
Your Name

Date(Required)

FULTON COUNTY
HEALTH DEPARTMENT

700 E. Oak Street
Canton, IL 61520

Phone (309) 647-1134 Fax (309) 647-9545

Medical Emergency? Dial 911.

After Hours Emergencies Contact Fulton County Sheriff 309-547-2277

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