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Initial Benefits Screen Interview

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General Information

What is your preferred language?How comfortable are you reading on your own?

Demographics & Residency

How old is the patient?Where does the patient currently live?Does the patient meet the residency requirement for public health insurance? (Citizen or legal resident)

Household income

Who is in the patient’s household?What does the patient do for a living?Does the patient receive financial support?What is the monthly patient (or household) income?

Dependents

Does the patient have any dependents?How old are the dependents?Do the dependents have insurance?

Coordination of Care

Has the patient received care at MSH before?Has patient been to REAP or FS before?Has the patient ever had insurance in the past? Have they ever applied for PHI?What days and times is the patient available for referral appointments?