JPS Application Form PDF Details

The JPS Health Network Application for JPS Connection Program is a comprehensive document designed to assess an individual or family's eligibility to receive medical care benefits under the JPS Connection Program. This form requires applicants to provide detailed information about their residency, personal demographics, income, and assets to ensure they meet the program criteria. Proof of residence, such as a utility bill or lease agreement, along with identification documents like a driver's license, birth certificate, and social security cards are fundamental requirements for the application process. The form also asks for detailed income and asset information from every adult member of the household, unless the application is for an adult child and the parents are not applying for coverage. This includes income from various sources such as employment, self-employment, unemployment benefits, child support, pensions, and any other benefits or income received, along with the value of significant assets and major monthly expenses. Applicants must certify the truthfulness of the information provided, with a stern warning that misrepresentation may lead to criminal penalties and loss of benefits. By signing the application, individuals also authorize JPS Health Network to conduct a credit check, which plays a part in the preliminary determination of eligibility, indicating the program's thorough approach to verifying an applicant's financial situation. This introductory insight into the JPS Application form highlights the essential steps and requirements for those seeking assistance through the JPS Connection Program, emphasizing the importance of accuracy and honesty in the application process.

QuestionAnswer
Form Name JPS Application Form
Form Length 1 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 15 sec
Other names jps health network, jps financial assistance application, jps connection, jps online application form

Form Preview Example

JPS Health Network

Application for JPS Connection Program

*Must provide proof of residence (example - utility bill, lease agreement)

5/9/07

Name: ___________________________________________________________________________Maiden Name: _____________________

(Last)

 

 

(First)

 

(MI)

 

Address:________________________________________________________________

Own Phone #: __________________

(Street)

(Apt. #)

(City)

(State)

(Zip)

(County)

Rent

Email Address: ________________________________________

 

 

 

Social Security Number: __________________________ Birth date: ___________________Place of birth :_________________________

Sex: Male

Female

Marital Status:

Single

Married

Divorced

Widowed

Have you ever received services through JPS Health Network? Yes

No

 

Is the patient pregnant?

Yes

No

 

 

 

 

 

 

 

 

 

List the names of each person living in household (attach additional sheets as necessary)

 

 

*Must provide copies of identification documents such as a drivers license or birth certificate, and Social Security cards

 

 

 

 

 

Name

Relationship

Date of

 

Social Security #

Employed

US Citizen /

 

 

 

Birth

 

 

 

 

Perm. Resident

1)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Y / N

 

 

2)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Y / N

 

 

3)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Y / N

 

 

4)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Y / N

 

 

Income & Asset Information – Required for each adult member of household

*Must provide proof of income and assets (example – 4 current check stubs, and bank statements, most recent tax returns; award letters)

Income and asset information is not required from parents of an adult child who is applying for JPS Connection if parents are not applying for JPS Connection coverage

1)

2)

3)

Name

Monthly Income

 

 

 

Employer Name

 

 

 

Employer Street Address

 

 

 

Employer City/State/Zip

 

 

 

Employer Phone #

 

 

 

Covered by employer health insurance (Yes/No)

 

 

 

Employment Income - monthly

$

$

$

Self employed income

$

$

$

Unemployment / Worker’s Compensation

$

$

$

Child Support / Alimony

$

$

$

Pensions / Retirement

$

$

$

Social Security (SSI) (Disability)

$

$

$

VA Benefits

$

$

$

Last income tax return filed

 

 

 

Gross taxable wages per tax return

$

$

$

Value of Assets

 

 

 

Property – value of home, land, buildings

$

$

$

Automobile – Yr/Make/Model

$

$

$

Bank Name(s)

 

 

 

Bank Account Balances

$

$

$

IRA/Other Investments

$

$

$

Major Expenses - Monthly

 

 

 

Mortgage Payments/Rent

$

$

$

Child Support/Alimony

 

 

 

Automobile payment (if applicable)

$

$

$

Other Loan Payments

$

$

$

"I understand that anyone who knowingly lies or misrepresents the truth or arranges for someone to knowingly lie or misrepresent the truth in the completion of this application is committing a crime which can be punished under federal law and/or state law. Everything on this application is the truth as best I know it." If at any time false information is discovered, penalties will include, but are not limited to, loss of my benefits and the inability to reapply for the JPS Connection Program for no less than a period of ninety (90) days. I authorize JPS Health Network to run a credit bureau report for the purpose of making a preliminary determination of whether I meet the eligibility requirements for the JPS Connection Program. I also understand that any approval will be conditional based on the information reviewed in my credit report.

Signature of Applicant: __________________________________________________________________________ Date: ___________________

Signature of Co-Applicant: _______________________________________________________________________Date: ___________________

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Stage number 1 of filling out jps application status

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jps application status writing process explained (portion 2)

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Part no. 3 of submitting jps application status

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