Phoenix Rising Re-Entry

You can use this checklist to create an overall picture of your network of benefits. When you review them, you may identify additional services that you need. At the end of this section is a list of resources that can help you in obtaining those services.

Medical Care and Services

I receive medical care from

My primary care physician is

Other medical services that I need include

Medical Insurance Coverage

What medical insurance coverage do you have?

Private Other Medicare Medicaid

Do you have additional coverage for medical expenses not covered by your primary policy?

Yes No

What is your Monthly premium $

What is your Annual deductible $

What is your Per Visit Co payment $

List the services that are covered

List the services that are not covered

Do you receive assistance to pay for deductibles, co pays, and monthly insurance premiums?

Yes No

If yes, what are the income eligibility requirements of that assistance?

HIV/AIDS Medications

Where do you get your medications?

How are they paid for?

Do you have limited or no drug benefit under your insurance policy(ies)?

Yes No

If yes, are you enrolled in an AIDS Drug Assistance Program?

Yes No

What is the income eligibility requirement of that program?

Housing Assistance

Are you currently receiving housing or rental assistance?

Yes No

If yes, how much assistance do you receive each month?

What is the income eligibility requirement of that program?

Are you receiving any other supportive services? If yes, describe

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