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Benefits Checklist

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:

I get my laboratory test and blood work done at:

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?

How much do you pay for:
  • Monthly premiums $
    Annual deductible $
    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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