Form Hea 7183 PDF Details

In the realm of public health services dedicated to assisting children with medical handicaps, the HEA 7183 form serves as a critical tool for families navigating the Ohio Department of Health's Children with Medical Handicaps Program (BCMH). This comprehensive document requests information to ensure a child receives the necessary support, covering areas from basic identification details such as the child's name, birth date, and residency status, to more intricate data regarding the family's financial situation, employment, health insurance coverages, and eligibility for other assistance programs. Crucially, it also entails consent provisions allowing the sharing of medical and fiscal information between healthcare providers, facilities, and insurers to facilitate or arrange services for the child. Additionally, by mandating the disclosure of any changes in employment status or income, alongside details about any pre-existing clauses in health insurance policies and the specifics of supplemental cover, the form aims to paint a complete picture of a family's circumstances. This enables the BCMH program to make informed decisions on eligibility and the extent of support required. Of paramount importance, the form underscores its commitment to confidentiality and adheres to the Health Insurance Portability and Accountability Act (HIPAA), ensuring sensitive information is shared responsibly and with the necessary permissions in place. Through this detailed documentation, the HEA 7183 form embodies the intersection of healthcare, social support, and legal consent, making it a cornerstone for accessing vital services for children with medical handicaps in Ohio.

QuestionAnswer
Form NameForm Hea 7183
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameshea7183 hea 7183 form

Form Preview Example

Ohio Department of Health

Children with Medical Handicaps Program (BCMH)

P.O. Box 1603, Columbus, Ohio 43216-1603

(614) 466-1700 OR 1-800-755-4769 • FAX (614) 728-3616

Release of Information and Consent

Child’s/client’s name

 

 

 

 

 

 

 

 

 

 

 

 

List all children in home currently involved with BCMH

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Case number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Birth date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

County of residence

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

U.S. Citizen?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

If NO, please submit a copy of U.S. Immigration Visa, I-94 , or other verification from the Immigration and Naturalization Services

 

 

(INS) regarding the CURRENT residency status for this child/client and his/her parents.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is child residing with parent(s)?

Is child/client self-supporting?

Marital status of child’s parent(s) with custody

 

 

 

 

 

 

Yes

No

 

 

Yes

No

 

Married

Widowed

 

 

 

Separated

Single

 

 

 

 

 

 

 

 

 

Divorced

Remarried

 

 

 

Natural parents residing together

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If child is not residing with parents, state your relationship to the child.

If this child was adopted, give date adoption became final.

 

 

 

Please submit a copy of guardianship/custody papers.

 

 

Please submit a copy of adoption decree.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does this child/client receive: (each line must be completed) $ Amount

 

 

 

 

Date applied

Date denied

1. Supplemental Security Income (SSI)

Yes $_______________

No

Denied

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. Social Security Disability Income (SSDI)

Yes $_______________

No

Denied

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. Medicaid Spend down

 

 

 

 

Yes $_______________

No

Denied

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. Medicaid/Healthy Start

 

 

 

 

Yes

 

 

No

Denied

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. Medicare

 

 

 

 

 

 

Yes

 

 

No

Denied

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6. Women, Infants and Children (WIC)

Yes

 

 

No

Denied

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Number of dependents claimed on

 

 

Gross Income of household last year

If child/client has Medicaid, what is the billing/recipient number

parent’s/client’s Federal Income Tax Form

 

(before taxes)

 

 

on the child’s/client’s medical card?

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Job and Family Services caseworker

 

 

 

 

 

 

 

Caseworker’s phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Who is currently employed?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Father

 

Mother

 

 

Self

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of employer

father’s,

 

mother’s,

self

 

 

Name of employer

 

 

father’s,

mother’s,

self

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer’s address

 

 

 

 

 

 

 

 

Employer’s address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

ZIP

 

City

 

 

 

 

 

State

 

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Work phone number

 

 

 

 

 

 

 

 

Work phone number

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IMPORTANT—please complete additional information on back

HEA 7183 11/13

page 1 of 2

Have you or your spouse changed jobs within the past year? If yes, give reason and give beginning and ending dates of all job changes within the past year.

Yes

No

Were you or your spouse unemployed this year or last year? If yes, give reason and give beginning and ending dates of unemployment.

Yes

No

If your income this year will be different from last year, give a full explanation. (If you have no income, also explain.)

Health insurance company that covers/child/client

 

 

 

 

Telephone number

 

 

 

 

 

 

 

 

(

 

 

 

 

 

 

 

 

 

 

 

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Policy holder

 

 

 

 

Policy number

 

Group number

 

 

Effective date

 

 

 

 

 

 

 

 

 

 

 

Is this child’s/client’s coverage limited by a pre-existing clause?

 

 

 

 

If this policy has a benefits cap, what is the lifetime maximum

Yes

No

If “Yes,” date clause expires

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

Does this child/client have dental insurance?

Vision Insurance?

 

 

Total amount you pay for health insurance per month (including dental and vision)

Yes

No

 

Yes

No

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Secondary health insurance company

 

 

 

 

Telephone number

 

 

 

 

 

 

 

 

(

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Policy holder

 

 

 

 

Policy number

 

Group number

 

 

Effective date

 

 

 

 

 

 

 

 

 

 

 

 

 

Release of Information and Consent

I hereby authorize my child’s/my managing physician or service coordinator to submit this application to the Ohio Department of Health, Children With Medical Handicaps Program, (herein after referred to as “BCMH”), for services for the child or client (hereinafter referred to as “client”) named on the front of this application

I authorize BCMH to release confidential information concerning the client’s medical condition and treatment, any and all financial information and third- party coverage to county and/or city health departments located in the city or county where the client lives or receives treatment and to health care and service providers, facilities and third-party payors (and their agents and employees) for the purposes of providing or facilitating the delivery of or arranging for services to the client. This authorization includes the release of any and all information concerning the client’s medical conditions and treatment, including if applicable, the client’s HIV testing or diagnosis of AIDS or AIDS-related conditions. I certify and attest that all the information given by me on this form and other BCMH application forms is true and accurate. I hereby give my permission to have all financial information verified. I authorize the release to BCMH of any and all information pertaining to my contract of insurance as to claims filed on behalf of client and amounts paid and to whom these claims or amounts were paid.

This release authorization is effective from the date of my signature and will remain in effect until such time as I expressly revoke it in writing. I understand that the above-referenced information will not be released to any other entity without an additional written release authorization from me or other person having legal authority to provide such release or as required by law.

I have read this authorization to release information and fully understand its contents and acknowledge receipt of the BCMH Health Insurance Portability and Accountability Act Privacy Notice.

When a child turns age 18, he/she (if possible) must sign this form. If the 18 year old is unable to sign, the parent or legal guardian may sign the form and provide a written explanation regarding the reason that the 18 years old cannot sign.

Unable to sign, state reason why:

Parent’s/legal guardian’s/client’s signature:

Date:

The best time of day to contact me by telephone is:

Parent’s/legal guardian’s/child’s email:

Someone not living with me who will know my address or how to contact me

Name:

Relationship to child:

Telephone number:

()

HEA 7183 11/13

page 2 of 2

Form Hea 7183 isn’t the one you’re looking for?

Related Documents