BOIS FORTE CONTRACT HEALTH SERVICE QUESTIONNAIRE

Bois Forte Health Services

5219 St. John’s Drive

Nett Lake, Minnesota 55772

218-757-3295 or 800-223-1041

CONFIDENTIAL INFORMATION

Head of Household _____________________________                    Telephone ____________________

Spouse/Maiden Name __________________________                    County _______________________

Address ______________________________________                      DOB _________________________

  City      ______________________________________                      State_______  Zip Code __________

Social Security Number _________________________

PLEASE LIST ALL OTHER MEMBERS OF HOUSEHOLD TO BE COVERED

NAME                                   TRIBE                                     DOB                       RELATIONSHIP                  SSN#

Applicant Blood Quantum _______________________________________________________________

Do you live on/off the Bois Forte Reservation _______________________________________________

Is any household member receiving Workers Compensation? __________________________________

If so, name, for how long and type of injury ________________________________________________

Does Applicant or any household member receive Social Security or SSI? ________________________

Does applicant or any household member receive VA? _______________________________________

Date eligible for VA _____________________                      Percent Disabled through VA _____________%

Is applicant or any household member, 18 years or older, attending any school, including high school, post secondary, technical college or university?

Name ___________________      School Name/Address ________________________________________

                                                                                                            ________________________________________

PLEASE ATTACH VERIFICATION OF STUDENT STATUS

MEDICAL INSURANCE

Does applicant or any household member have any medical coverage?                     YES           NO

Please include MA, Medicare, Medicaid, Private Insurance (ex. Blue Cross/Blue Shield)

Company Name/Address ________________________________________________________________

                                                  ________________________________________________________________

Group # _______________            Company Insured Through ____________________________________

Is this family or single coverage? _______________________

 If family coverage, please list who is covered: ______________________________________________

If you have Medicare/Medicaid, please list the number  ______________________________

Effective Date _____________________

DENTAL INSURANCE

Does applicant or any household member have dental coverage?          YES          NO

Company Name/Address ________________________________________________________________

                                                   ________________________________________________________________

Is this family or single coverage? _______________________

 If family coverage, please list who is covered: ______________________________________________

Effective Date ______________________

PLEASE ATTACH COPIES OF ALL INSURANCE CARDS

EMPLOYMENT

Employer ____________________________________  Date of Hire _____________________________

Address ______________________________________________________________________________

Work Phone Number __________________________  Full Time/Part Time? ______________________

Pay Period: (circle one)                Weekly                                Bi-Weekly          Monthly              Yearly

** PLEASE NOTE: If you are self employed, use most recent taxes for income verification

PLEASE ATTACH RECENT CHECK STUB/INCOME VERIFICATION

Signature _________________________________                              Date ____________________________

Did you remember to include?

·         Income Verification

·         Copies of Insurance Cards

·         This is necessary in determining your eligibility

Bois Forte Contract Health Service

Bois Forte Health Services

5219 St. John’s Drive

Nett Lake, Minnesota 55772

218-757-3295 or 800-223-1041

AUTHORIZATION AND RELEASE

Name ________________________________________                     DOB _______________________

Address ______________________________________                      SSN ________________________

                 ______________________________________

The undersigned hereby knowingly and voluntarily authorize the Bois Forte Contract Health Program:

1.       To obtain and disclose information necessary to determine eligibility for services from or through the Bois Forte Contract Health Services (CHS);

2.       To discuss information regarding my accounts with service providers, including but not limited to hospitals, clinics, collection agencies and financial institutions;

3.       To obtain and disclose information to third parties when necessary to satisfy alternate resource [1] requirements.

I hereby authorize persons or entities, which possess or maintain information about me to disclose that information to Bois Forte CHS for the purposes set forth above.

THIS IS NOT A CONSENT TO DISCLOSURE OF MEDICAL RECORDS

A copy of this authorization shall have the same fore, effect and validity as the original.

This authorization and release shall be valid from the date below, up to one (1) year. (If the authorization and release also relate to the minor children of the originator, it shall be valid until the 18^th birthday of each of the named children.)

Signature _____________________________________                     Date ____________________________

Parent/Guardian of children named below:

(circle one)

Name ________________________________        DOB _________________              SSN ________________

Name ________________________________        DOB _________________              SSN ________________

Name ________________________________        DOB _________________              SSN ________________

Name ________________________________        DOB _________________              SSN ________________