Connecticut Medical Home Initiative for Children and Youth with Special Health Care Needs* FAVOR

Connecticut Medical Home Initiative for Children and Youth with Special Health Care Needs* FAVOR
185 Silas Deane Highway
Wethersfield CT 06109
Tel: 860-436-6544 Toll Free: 855-436-6544
Fax: 860-563-3961 Email: CTMedicalHome@FAVOR-ct.org

PROGRAM APPLICATION
Date

MonthDayYear
Referred By:
Child's Information
Name

First NameLast Name
Sex

MF
Date

MonthDayYear
Social Security Number
To be eligible for Respite funds or ESF this is required
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preffered Language
Hispanic:

YesNo
Race:

WhiteBlackAsian/Pacific IslanderNative AmericanOther (Specify)
Parent/Guardian Information

Parent/Guardian Information

Rows	Name	Cell Phone	Work Phone	Home Phone	Email
Mother
Father
Other

Preferred Method of Communication:

MailEmail
Does your child receive any of the following?
Social Security Income:

YesNo
Does your child receive any of the following?

Husky AHusky BHusky B+Husky CKatie Beckett WaiverPrivate Insurance:
Husky Health Plan ID#
Private Health Plan ID#
Other Financial Support:

YesNo
If yes, please specify source
(* i.e. Cystic Fibrosis Foundation, Pharmaceutical Subsidy, MDA, UCP, Lions' Club, Shriner's, etc.)
Is your child:

over the age of 18?a Full-time student?employed?
Child Questions:

Does your child live out of the family home?Does your child attend a Day Program?Is your child on a wait list for a day program?
Mother's Information
Name

First NameMaiden NameLast Name
Birth Date:

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number
Required for funding
Legal Guardian:

YesNo
Marital Status:

SingleMarriedDivorcedSeparatedWidow
Employer:
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Health Insurance:
Health Insurance ID #
Health Insurance Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Health Insurance Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father's Information
Name

First NameMaiden NameLast Name
Birth Date:

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number
Required for funding
Legal Guardian:

YesNo
Marital Status:

SingleMarriedDivorcedSeparatedWidow
Employer:
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Health Insurance:
Health Insurance ID #
Health Insurance Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Health Insurance Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact information for legal guardian if other than the parent(s)
Name

First NameLast Name
Social Security Number
Guardian Relationship:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Family Income Information

Family Income:

Rows	Amount
Child’s Monthly SSI/SSDI
Monthly Retirement
Monthly Alimony
Monthly Child Support
Monthly Temporary Family Assistance (TFA)
Other

Annual Income:

Rows	Amount
Father income OR SSI/SSDI
Mother income Or SSI/SSDI
Total Annual Income
Number of Children living in the house
Number of Adults living in the house

PLEASE ATTACH A COPY OF YOUR MOST RECENT TAX RETURN OR
FOUR CONSECUTIVE PAYSTUBS AS PROOF OF INCOME
INFORMATION ON CHILD's SPECIAL HEALTH CARE AND MEDICAL NEEDS

Child’s diagnosis(es)

Rows	Child’s diagnosis(es)
1. Primary Diagnosis
2. Secondary Diagnosis
3. Other Condition
4. Other Condition

Child’s Primary Health Care Provider
Providers Name:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child’s Dental Provider
Providers Name:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child’s Specialty Care Provider(s)
Specialist 1 Name
Specialist 1 Specialty
Specialist 1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Specialist 1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Specialist 2 Name
Specialist 2 Specialty
Specialist 2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Specialist 2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Specialist 3 Name
Specialist 3 Specialty
Specialist 3 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Specialist 3 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Does your child have need of services that they are not currently receiving? (Example: Medication, Support Groups, Care Coordination, Special Education, Daycare or equipment etc.)

YesNo
If Yes, please describe:
If you have any matters or questions regarding your child that was not mentioned or covered by this form, please indicate below.
Names of other children with special health care needs in the family currently in this program.
*The Connecticut Medical Home Initiative for Children and Youth with Special Health Care Needs
is a program supported by the State of Connecticut Department of Public Health.
Information is available on their website at www.ct.gov/dph/medicalhome
For Office Use Only
Eligible for Extended Service Funds:

YesNo
If NO, Explain reason:
Should be Empty:

Connecticut Medical Home Initiative for Children and Youth with Special Health Care Needs* FAVOR

Child's Information

Parent/Guardian Information

Does your child receive any of the following?

Mother's Information

Father's Information

Contact information for legal guardian if other than the parent(s)

Family Income Information

INFORMATION ON CHILD's SPECIAL HEALTH CARE AND MEDICAL NEEDS

Child’s Primary Health Care Provider

Child’s Dental Provider

Child’s Specialty Care Provider(s)

For Office Use Only