USVI Public Records

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GOVERNMENT OF THE UNITED STATES VIRGIN ISLANDS DEPARTMENT OF HUMAN SERVICES _________________________________________________________________ VI STATE PHARMACEUTICAL ASSISTANCE PROGRAM SPAP APPLICATION MEDICARE I.D HICN. # ______________________________ DATE_______________________ NAME ________________________________________________________________________________________ Last First Initial SOCIAL SECURITY #________________ DATE OF BIRTH______________ PLACE OF BIRTH ______________ ADDRESS: (PHYSICAL) _______________________________________________________________________ (MAILING) _______________________________________________________________________ TELEPHONE NUMBER: (HOME) _____________ (WORK) _______________ (CELL) _______________ CITIZENSHIP STATUS: A. Alien__ B. U.S. Citizen__ C. Resident Alien (Green Card) ___ ETHNICITY: A. Black____ B. Caucasian _____ C. Hispanic _____ D. Other _____ MARTIAL STATUS: Married___ Single___ Divorced___ Widowed___ Separated ____ NAME OF SPOUSE / CONTACT PERSON: ___________________________________________ (H) _______________________ (W) ________________________ (CELL) __________________________ ADDRESS: _____________________________________________________________________________________ EMPLOYMENT STATUS: A. Unemployed ___ B. Part-time employment___ C. Retired____ D. Full-time employment___ E. Are you interested in Employment? Yes____ No _____ Name of Employer ____________________________________________________ Address ____________________________________________________________ Phone __________________ HEALTH INSURANCE & PRESCRIPTION DRUG COVERAGE INFDORMATION: PLEASE INDICATE CURRENT INSURANCE & PLAN. CIRCLE ALL THAT APPLY. MEDICARE PART A MEDICARE PART B MEDICARE PART D MEDICAID OTHER____________________ ____________________ IF OTHER INDICATED PLEASE SUBMIT A COPY OF YOUR CARD(S) WITH THIS APPLICATION Please list current doctors and date last seen. Doctor Date Last Visited _______________________ ______________ _______________________ ______________ _______________________ ______________ What is the state of your health? Fair ___ Good ___ Excellent ____ Average___ Poor___ Do you have any ailments? ________________________________________________________________________ Do you have difficulties taking care of yourself? Yes ___ No ___ If yes, what are those difficulties? __________________________________________________________________ ______________________________________________________________________________________________ Please list medications that you are currently taking? ______________________________________________ _________________________________________________________________________________________ What are your food/drug allergies? _______________________________________________________________ ___________________________________________________________________________________________ SERVICES RECEIVED/ NEEDED: Mental Health Services ___ Home Delivered Meals___ Homemaker Services___ Home Health Care ___ Income Maintenance ___ Adult Protective Services___ Housing ___ Educational (U. V .I.) ___ Medical Assistance ____ Social Security ___ Food Stamps ___ Other ___________________________________________________________ CERTIFICATION AND AUTHORIZATION I CERTIFY THAT THE INFORMATION ON THIS FORM IS TRUE AND ACCURATE. I UNDERSTAND THAT IF I PROVIDE FALSE, FRAUDULENT OR MISLEADING INFORMATION, I FACE FINES AND PENALTIES UNDER VI LAW. I AUTHORIZE THE SOCIAL SECURITY ADMINISTRATION, BANKING INSTITUTIONS, PRIVATE INSURANCE COMPANIES, AND OTHERS TO RELEASE INFORMATION NECESSARY TO DETERMINE MY VI SPAP ELIGIBILITY. I AUTHORIZE THE VI SPAP TO RELEASE INFORMATION ABOUT ME., IF APPLICABLE, AS NECESSARY FOR RECEIPT OF VI SPAP BENEFITS AND MEDICARE PRESCRIPTION BENEFITS AND OR THE ADMINISTRATION OF THE VI SPAP PROGRAM, AS PERMISSIBLE BY FEDERAL OR LOCAL LAW. I FURTHER AUTHORIZE MY HEALTH CARE PROVIDER TO RELEASE ALL MEDICAL RECORDS PERTAINING TO PRESCRIPTIONS COVERED BY VISPAP TO ASSURE THAT THE SERVICES PAID FOR BY VI SPAP WERE APPROPRIATE. APPLICANT SIGNATURE/MARK__________________________________ DATE___________________ AUTHORIZED REPRESENTATIVE/POWER OF ATTORNEY/CONSERVATOR CONTACT INFORMATION: IF THE APPLICANT IS UNABLE TO SIGN FOR THEMSELVES PLEASE ATTACH PROOF OF RELATIONSHIP AS THE AUTHORIZED REPRESENTATIVE, POWER OF ATTORNEY, OR CONSERVATOR. NAME: ____________________________________ RELATIONSHIP: _________________________________ ADDRESS: __________________________________________________________________________________ TELEPHONE: ______________________________ E-MAIL:________________________________