Name: Cecilia Williams
Age: 64 Years
Preventive Care Initiatives - Eligibility Form for U.S.-based Provider
Marital Status: Married
Date: May 1
Number of dependents: 2
Income for previous four months.
Expected income for next three months.
January: $300
May $300
February: $400
June: $325
March: $300
April: $350
July: $350
High Blood Pressure.
X Migraines
Nausea
Cough
Sore Throat
Recent Medical Symptoms and Conditions
Please mark any symptoms or conditions experienced in the past month.
Headaches
Vomiting
X Fever
X Dizziness
X Blurred Vision
Hearing Loss
Muscle Aches
Diabetes
Arthritis
Chest Pain
Program A
Income (previous three months): Average of $400/month
or less AND no single month over $500
Age: 50 to 70 years old
Symptoms: Must have at least 2 symptoms including
coughing
Program Qualifications
Program B
Income (previous three months): Three-
month total not more than $1000
Age: 55 to 65 years old
Symptoms: Must have at least 4
symptoms including migraines and fever.
Program C
Income (previous three months): Three month
total not more than $800
Age: 63 years old or older
Symptoms: Must have at least 6 symptoms
including blurred vision and diabetes.
Cecilla Just started a new job. Since she is expecting an adjustment in her income level, she wants to know which programs she will be eligible for on August 1st.
taking into account her expected change of income.
17:54
Question 17
She will be eligible for which program(s)?
Program A
Program B
Program A and Program B
Program A, Program B. and Program C
Cecilia will not be eligible for any of the programs.