PROFILE INFORMATION-HOSPITAL CARE FOR THE INDIGENT
State Form 42834 (R3 / 1-96) / OFE 0133A
Applicant is financially eligible for the following month(s):
Last Name First Name HCI Mo. Day Year Case Number Date County Office Took Action Social Security Number Mo. Mo. Day Day
(FSSA Use Only) Signature of County Director or Authorized Designee Date Supporting regulation: Applicant is financially ineligible for the following month(s):
Year Year
Date of Birth Date Application Received By County Office Date FSSA Took Action
Reason:
CIRCLE NUMBER NEXT TO APPROPRIATE RESPONSE 1 2 A. Application for HCI approved? Yes No B. Denial code C. Is patient an Indiana resident? Yes No Unknown D. Is patient SSI recipient? Yes No Unknown E. Race White Black Hispanic American Indian Asian Multiracial Other Unknown F. Sex Male Female Unknown G. Household status Single adult Single adult with children Married adult without dependent child under 18 Married adult with dependent child under 18 Married adult with youngest child between 18-21 Dependent child under 18 years old Dependent child 18-21 years old Unknown H. Is patient or parent / spouse of patient employed? Yes No Unknown I. Household size One Two Three Four Five Six or more Unknown J. Total countable net income used in establishing patient's eligibility Actual net income (to the nearest dollar) Unknown K. Reason for care Pregnancy related Illness (physical illness only) Accident Other (specify) Unknown L. Health insurance Yes No Unknown M. Primary diagnosis
1 2 3
1 2 3
1 2 3
1 2 3 4 5 6 7
1 2 3 4 5 6 7 8
$ X
1 2 3 4 5
1 2 3
1 2 3
1 2 3 4 5 6 7 8
N. ICD-9-CM Code (number) (FSSA use only)