CATCH Patient Eligibility Form Safety Net Clinic*Client's Name* First Last Client Date of Birth* Date Format: MM slash DD slash YYYY Client's Phone Number*Home, Work, or CellClient's Address* Street Address City ZIP / Postal Code Client's Email*Family size*Income before taxes (dollar amount)*Please indicate if monthly or annual incomeInsurance Status*Is the patient covered by any of these programs? Check all that apply. Medicaid Medicare Private Insurance Workplace-sponsored insurance CICP OtherMedicaid Status*Safety Net Clinic has called to verify current Medicaid status (CCHA Member & Provider Support at 719-598-1540) on date: Date Format: MM slash DD slash YYYY Medicaid*YesPatient does not meet income guidelines for MedicaidPatient is determined to be unable to apply for Medicaid (undocumented, etc.)Clinician Signature BelowClinic Staff Signature* Mr.Mrs.MissMs.Dr. Prefix First Last Signing Consent* By checking, this Form may be executed and delivered by electronic means and upon such delivery the electronic signature will be deemed to have the same effect as if the original signature had been delivered to the other party.Date of referral*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920