Medical Care Available for Uninsured Children - Office of Partnerships

Partnerships:

Medical Care Available for Uninsured Children

Are you:

Family Size	Annual Income	Monthly Income
1	$26,000	$2,166.67
2	$35,000	$2,916.67
3	$44,000	$3,666.67
4	$53,000	$4,416.67
5	$62,000	$5,166.67
To find out if your child qualifies for FREE or low-cost health care, please complete and submit this form to receive more information.

Parent / Guardian Name:

Address:

Suite/Apt #: City:

State: Zip:

Number in Family:
Total Family Income*:

Home Phone:
Work Phone:

Best Time to Call:
Primary Language Spoken:

E-mail:

this Feedback Form or to begin again.

*Monthly income before taxes are deducted