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Printable Form 4180 Vallejo California: What You Should Know

If a patient's last name was not provided, use the last name in the Patient Information Area o Enter the patient's Age, Date of Birth, Spouse's name, Mother's name, and Date of Delivery ◇ Patient Relationship o If married, enter “Married” under the Spouse's Name Patient's Social Security Number Patient's Address o Enter both of the patient's full address at the time of application, or the address that you live with or occupy. ◇ Additional Information about the Patient Medical History For Patients who were born on or after January 1, 1982, choose this option: ● I have: ● • Inpatient and Day Treatment (I/D) admission records for my first 3 years (if applicable) ● Inpatient treatment records for ● If I am under 65 years of age, medical records with dates of treatment and/or diagnoses for all my inpatient hospitalizations ● Before December 12, 1997, records with dates of admission, discharge and treatment ● Before I met you, I am not currently under the jurisdiction of the U.S. Department of Health and Human Services (HHS), Health and Human Services Department (HHS). ● I am 65 or older who was under 65 when I met you and: ● I am a U.S. Citizen, Permanent Resident, or Alien ● I am not under the jurisdiction of HHS HHS but who met you for longer than 3 months, including at a mental health facility ● I have been diagnosed by my doctor as having a significant mental illness, a personality disorder, or a substance abuse disorder, that results in a significant limitation in activities. [If you chose the first option above, your doctor should give you a psychiatric evaluation or a psychological evaluation for more detailed information to make sure you cannot pay any fines due to failure to pay.] ◇ Financial information for each of your family members and yourself who is currently in the United States (as well as your family members if you are a green card holder) may be required. Some applicants might also be required to furnish certain tax returns that were filed during the calendar year in which you or your dependent filed their tax returns. For this purpose, your name, your address and your date of birth will be required.

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