Jps Connection Application PDF Details

In order to ensure that all potential students have access to the resources they need, Jps Connection has created an application form. This form allows the school to assess each student's needs and create a personalized learning plan for them. In addition, the form helps to connect parents and guardians with appropriate resources in their area. For more information on how to complete the Jps Connection Application Form, please visit our website.

If you wish to first determine how much time you need to fill out the jps connection application and what number of pages it's got, here's some basic data that could be helpful.

QuestionAnswer
Form NameJps Connection Application
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namesjps connection application form pdf, jps eligibility, jps connect, jps application

Form Preview Example

Dear Applicant:

Welcome to JPS Health Network. We look forward to providing affordable health care to you and your family. The purpose of the JPS Connection program is to create a healthier community by providing discount health services to Tarrant County residents. Connection cardholders have the benefit of a medical home – meaning you have a physician or nurse practitioner assigned to you and your family. You get access to preventative care – such as physicals and screenings that will help keep you healthy and out of the emergency room.

Inside this packet you will find the application and the documentation requirements for our JPS Connection program. Please complete the enclosed application and submit it along with supporting documentation. You may call our Eligibility Center at (817) 702- 1001 should you need assistance, our staff members are happy to answer any questions you may have.

For your convenience we offer the options to apply by mail, through our website or fax. You may submit your completed application and supporting documentation to the addresses or fax number below.

JPS Eligibility Center

1325 South Main Street

Fort Worth, TX 76104

Email: Enroll@jpshealth.org

Fax (817) 927-3834

Processing time may vary according to the number of applications received. We will contact you once an eligibility determination is made or if additional information is required. You may contact us at the above mentioned numbers or email to check the status of your financial screening. Thank you for choosing JPS and we look forward to providing quality healthcare to you and your family.

Regards-

Doris Hunt

Vice President of Finance

Revised: 4/16/13

JPS Health Network

Application for JPS Connection Program

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

04/02/12

Name: ___________________________________________________________________________Maiden Name: _____________________

(Last)

 

 

 

(First)

 

(MI)

Live w/ someone

 

 

 

 

 

 

 

Rent

Home #: _________________

Address:________________________________________________________________

Own

Cell#: _____________________

(Street)

(Apt. #)

(City)

(State)

(Zip)

(County)

 

Please check primary contact phone number

Are you a Tarrant County Resident?

Yes

No

Email Address: ______________________________________________

Primary Language: English Spanish Vietnamese Other _________

Marital Status: Single Separated Divorced Widowed Married** (If married, spouse’s signature is required)

Ethnicity: Caucasian African-American Hispanic Asian Native American Other ______________________

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

*Must provide copies of identification documents such as a driver’s license or birth certificate, Immigration cards and Social Security cards

Full Name of Household

 

 

 

 

 

Members:

 

 

 

 

 

Relationship to applicant:

Self

Spouse

Child

Child

Child

Sex:

Male Female

Male Female

Male Female

Male Female

Male Female

Date of Birth

 

 

 

 

 

 

 

 

 

 

 

Place of Birth

 

 

 

 

 

 

 

 

 

 

 

Check one if applicable:

US Citizen

US Citizen

US Citizen

US Citizen

US Citizen

 

Perm. Resident

Perm. Resident

Perm. Resident

Perm. Resident

Perm. Resident

Social Security #

 

 

 

 

 

 

 

 

 

 

 

Employed?

Yes / No

Yes / No

Yes / No

Yes / No

Yes / No

Is pregnant?

Yes / No

Yes / No

Yes / No

Yes / No

Yes / No

Insurance, Medicaid, Medicare?

Yes / No

Yes / No

Yes / No

Yes / No

Yes / No

 

 

 

 

 

 

Is a Veteran?

Yes / No

Yes / No

Yes / No

Yes / No

Yes / No

Indicate persons applying

Yes / No

Yes / No

Yes / No

Yes / No

Yes / No

Monthly Income & Asset Information – Required for each member of household that receives income

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

Each box below must be addressed. Place a -0- or N/A in box if not applicable. Incomplete applications will be returned.

List household members names

1)

2)

3)

4)

Employer Name

 

 

 

 

Employer Street Address

 

 

 

 

Employer City/State/Zip

 

 

 

 

Employer Phone #

 

 

 

 

Employment Income - monthly

$

$

$

$

Self-employed income

$

$

$

$

Unemployment / Worker’s Compensation

$

$

$

$

Child Support / Alimony

$

$

$

$

Pensions / Retirement

$

$

$

$

Social Security (SSI) (Disability)

$

$

$

$

VA Benefits

$

$

$

$

Year of last income tax return filed

 

 

 

 

Gross taxable wages on tax return

$

$

$

$

Value of Assets

 

 

 

 

Property – value of home, land, buildings

$

$

$

$

Bank Name(s)

 

 

 

 

Bank Account Balances

$

$

$

$

IRA/CD/401k/403b & 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 understand I am responsible for reporting any change in residence, household income, employment, family size or insurance coverage. I understand my membership will be put on hold if a change is not reported.” 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/Spouse: _______________________________________________________________ Date: __________________

Spouse’s signature is required to complete screening even if spouse is not requesting assistance at this time.

Provide all

JPS Health Network

Documentation Requirements for

JPS Connection Indigent Healthcare Program

** Please provide all applicable items from following categories **

Please note that upon receipt of documentation additional information may be requested.

Proof of Patient Identification - Must provide one of the following:

Driver’s license or DPS ID card

Birth Certificate (children under 18)

Employee Identification card (with picture)

School Identification card (with picture)

Immigration documentation - for all applicable household members:

Resident alien cards (front and back), Visas and or Passports

Bank Statements & Tax ReturnsMust be provided

Most recent checking and savings account statements

Entire 1040 Tax Return Form with: Schedule C, Partnership tax form 1065, Schedule K-1, Schedule F, W2 etc.

Most recent statement of CD’s, IRA’s and other investments

Proof of Employment and IncomeMust provide applicable sources of income

Four most recent payroll check stubs

Employment Verification form

Current award letter / copies of checks: SSI, RSDI, VA, Soc. Sec., TANF

Workman’s Compensation

Employer statement of earnings on letter head

Court orders/check or debit card statement for Child Support /Alimony

Unemployment Award letter, check stubs or Chase debit card statement

Debit/Payroll card statements (if applicable)

Verification sources of assistanceapplicable

Food Stamp/TANF and Housing Assistance award letters

Statement from Homeless Shelter where patient resides and verifying unemployment.

Verification of Assistance form with notary seal and all of the following proofs from the person providing assistance:

Utility bill

Proof of income (upon request)

Social Security NumberProvide for all applicable household members.

Proof of Patient ResidencyMust provide a minimum of two

Utility, telephone and cable bills

Lease agreement, rent receipt, mortgage statement

Auto, Life, Homeowners/Renter’s Insurance Documents

County, State/Federal agencies Correspondence

Retirement Plan Documents, Attorney Correspondence

Texas Department of Motor Vehicle Records

Statement from Homeless Shelter

Proof of InsuranceProvide for all household members

Front and back of Medical/Dental Insurance cards

Proof of Self Employment (No taxes withheld from income)

Self Employment Form (1 form each month)

Entire 1040 Tax Return Form with: Schedule C, 1099, Partnership Form 1065, Schedule K-1, Schedule F etc.

Business ledgers/Accountant’s statement listing income and expenses for the last 12 months

12 months of check stubs, receipts, or logs for income received: babysitting, contract/sub-contract work, landscaping, day labor work etc.

Acceptable sources to verify deductions

If desiring to claim deductions for child care, alimony or child support paid out:

Statement listing last four payments to provider

Last four canceled checks

Copy of divorce decree stating amount owed

Statement from Attorney General’s office

Statement from ex-spouse itemizing payments

Assets, Debts & LiabilitiesMust provide if applicable

Certificate or dividend statement

Car title / make, model and value

Individual Retirement Account

Proof of insurance policies

Property tax statement or deed/title

Oil, gas, mineral rights (bring statement)

Car loan agreement or statement

Unpaid medical bills

Lending institutions account #’s & available credit line

PLEASE NOTE - Anyone who knowingly lies or misrepresents the truth or arranges for someone to knowingly lie or misrepresent the truth in the completion of the application process is committing a crime, which can be punished under Federal law, State law, or both. If at any time false information is discovered penalties will include, but are not limited to, loss of my membership benefits and the inability to reapply for the JPS Connection Indigent Healthcare Program for no less than a period of ninety (90) days.

Revised 11/19/10

JPS Health Network

Membership Responsibilities for

JPS Connection Indigent Healthcare Program

______ I understand that the JPS Connection does not cover all of the services provided at JPS Health

Network including, but not limited to, dental, podiatry, cosmetic procedures, assisted reproductive technology and transplants.

______ JPS Connection is a tax-supported medical program offered to eligible Tarrant County residents.

JPS Connection offers low cost medical care available only through JPS Health Network facilities. I understand that JPS Connection is not an insurance company or an insurance plan.

______ At this time, I am not covered under any third party commercial insurance, Medicaid and/or parts

A&B of Medicare. I understand that if I am deemed eligible for state, federal or pharmaceutical assistance programs, I must comply with seeking that assistance. Failure to do so will make me ineligible for JPS Connection. Documentation provided to JPS Health Network will be used to apply for any coverage for which I may be potentially eligible.

______ I am aware that when JPS Connection is used secondary to another payor, I am responsible for all

physician/professional fees, co-payments and any deductibles related to professional services rendered. This includes, but not limited to, JPSPG, UNT, Sheridan, RadCare, EmCare or any other professional group you may receive bills from.

______ As a JPS Connection member, I understand that I have an obligation to notify the Financial

Screening department of JPS Health Network of any changes. I agree to inform the Financial Screening department of the JPS Health Network immediately of any changes in my Tarrant County residence, household income, family size and insurance coverage.

______ I understand that the JPS Connection membership privileges are on a limited time basis. In order

to continue receiving a discount on medical services, through the JPS Connection program, it will be necessary to complete another financial screening at the end of my enrollment period. You will be expected to pay all charges incurred after eligibility has expired.

______ I acknowledge that should the JPS Health Network receive returned mail, from the mailing

address I provided, that my JPS Connection membership privileges will be suspended pending further review.

______ I understand that I am responsible for providing true and accurate documentation. If at any time

false information is discovered penalties will include, but not limited to, loss of my membership benefits and the inability to reapply for the JPS Connection Indigent Healthcare Program for no less than a period of ninety (90) days.

"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, State law, or both. Everything on this application is the truth as best I know it."

Signature of Applicant: _______________________________________ Date: _______________

Signature of Co-Applicant: ____________________________________ Date: _______________

1/25/08

JPS Health Network

Verification of Assistance and Residency for

JPS Connection Program

This form only needs to be completed if the applicant is being assisted by another individual.

I, ___________________________________________ verify that ___________________________________________

Name of person providing assistanceApplicant(s) full name

Patient’s MR# _____________________________ and/or Social Security # ____________________________________

lives at ___________________________________________________________________________________________

Applicant(s) AddressCity/Zip Code

Financial Assistance: I provide financial assistance to the applicant. Yes

No

This individual is claimed as a dependent on my more recent filed income tax return.

Yes No

Does the applicant have a job? _____________ If yes, provide employer name__________________________________

Does the applicant have another income source? _____________ If yes, how much

___________________________

I provide applicant with the following: Food Personal items

Transportation

Cash/Check $ _____________ per Week or Month

Other ____________________

Do you pay rent or other bills for this applicant? ____________ If yes, how much and how often? __________________

Residency Assistance:

The applicant(s) resides at my Tarrant County residence.

The applicant(s) does not pay rent to me.

The applicant(s) pays ____________ to help toward the rent and utilities. How long has the applicant(s) resided at your address? _______________

Does the applicant(s) have another residence? ___________ If yes, where _________________________________

Documentation Attached for Person Providing the Assistance:

Provide proof of residence (if applicant lives with the person providing the assistance ) refer to proof list

Provide proof of income (only upon request)

Relationship of Person Providing the Assistance to the Applicant(s): ___________________________________

I certify that the above information is true and correct. "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.”

Signature of the Person Providing the Assistance: _________________________________________________

Address, City, State, Zip: _________________________________________________

Phone Number: _________________________________________________

Date signed: _________________________________________________

Revised 04/17/13

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