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Patient Questionnaire
Patient Questionnaire
A problem was detected in the following Form. Submitting it could result in errors. Please contact the site administrator.
Required*
What is today's date?
Patient's Full Name
Date of Birth
Do you have health insurance?
Yes
No
Please select the type of insurance:
Medicaid
Medicare
Share of Cost
UF Health City Contract
Affordable Care Act Plan
Private insurance plan
Private dental plan
Other
Do you have a primary care doctor?
Yes
No
Please provide the name, the address, if known and the contact number of your Primary Care Doctor.
Please provide your email address if you have one.
Please provide your current address
Please provide a phone number where you can be reached
What is your family size? (Include yourself, your spouse/partner, children under 18, students under 21, and unborn children)
Are you employed?
Yes, I work full time.
Yes, I work part-time.
No, I am not currently employed.
What is your estimated household income for the past 4 weeks?
Please describe your most immediate needs and level of urgency
Are you the patient completing this application or are you completing this application for someone else?
I am the patient.
I am completing this application for the patient.
Other.
Is there anything else we should know?
Submit Questionnaire
2023 FEDERAL POVERTY LEVELS
Size of
Household
150%
monthly
150%
yearly
200%
monthly
200%
yearly
250%
monthly
250%
yearly
1
$1,823
$21,870
$2,430
$29,160
$3,038
$36,450
2
$2,465
$29,580
$3,287
$39,440
$4,108
$49,300
3
$3,108
$37,290
$4,143
$49,720
$5,179
$62,150
4
$3,750
$45,000
$5,000
$60,000
$6,250
$75,000
5
$4,393
$52,710
$5,857
$70,280
$7,321
$87,850
6
$5,035
$60,420
$6,713
$80,560
$8,392
$100,700
7
$5,678
$68,130
$7,570
$90,840
$9,463
$113,550
8
$6,320
$75,840
$8,427
$101,120
$10,533
$126,400