Centauri HS - Eligiblity Screening

Hello! Thank you for visiting our benefits pre-screening web page.

This is a secure site. This screening is confidential and free to you. The questions are simple, and this should only take a few minutes.

Identification number from letter received.

ID:

Your name as it is listed on the letter you received:

First Name: (required)

Last Name: (required)

Date of Birth
(Providing your DOB we allow us to more accurately provide results)

What is your state of residence?

State:

What is your citizenship?

Citizenship:

What phone number and time of day are best for you to be contacted?

Phone number (required):
Send me information using text messages Time of day:

If you would like to receive communication from Centauri Health Solutions via email, please provide your email address:

E-mail address:

Does the patient have health insurance?

Yes No

Covid-19 (aka Coronavirus) Questions

Have you tested positive for COVID-19:

Test Date:

In the following tables, fill in the values based upon all assets owned by the people currently living in your "home" that can be counted as part of your "household group".
Household Group - Answer this question as if you are one of the adults responsible for supporting the household. Based upon this, the following individuals are to be included if they are living in your home: Yourself, your spouse, your partner if you have a child between the two of you who is not married, under 18 and still living in your home, any natural or adopted children if they are under 18 and not married. Do not include your parents if you are over 18 years old.

Income:

Income Type

Admit Month

Work Wages $

Child Support $
(Details for 1 Child are needed for Child Support Income)

Unemployment $

Workers Compensation $

Supplemental Security Income (SSI): $

Social Security Disability (SSD): $

Social Security Retirement: $

Pension/Retirement: $

Other Income: $

Resources:

Resource Type

Estimated Value

Cash & Cash Equivalent $

Automobiles: Second Vehicle $

Retirement Accounts $

Investment Accounts $

Life Insurance: Cash Value $

Burial Accounts: Cash Value $

Other Assets: $

Is the patient married?

Yes No

Is the patient under the age of 18?

Yes No

Is the patient between the ages of 19 and 21?

Yes No

Is the patient pregnant?

Yes No

Does the patient have biological or adopted children in the household who are under 18 years of age?

Yes No

Does the patient have any of the following conditions:

Presumptive Conditions:

Has the patient been told by a doctor that he/she is unable to work for at least the next 12 months, due to a medical condition?

Yes No

Thank you very much! Now just click on the "Done" button...

Patient Screening Survey