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1. My child's diagnosis is
2. Here is a list of services your child may use. Please tell us whether Medicaid pays for some or all (even if Medicaid is the secondary coverage), if you have any out-of-pocket costs for the service, and how much. And then use the drop down box to tell us how often

How oftenDoes Medicaid pay?Do you have out of pocket costs?If you have out of pocket costs, how much per service?
Primary care (pediatrician or family doctor)
Specialty care
Medications
Diagnostic tests
Diagnostic x-rays and other radiology
Physical therapy
Speech therapy
Occupational therapy
In home/in school nursing
In home/in school nurse's aide
Medical equipment
Medical supplies
Outpatient behavioral health
Wraparound services (TSS, etc.)
Other behavioral therapies/psychiatrist/psychologist
Other
3. Do you pay a premium (or have $ deducted from your pay) for your child to be on your private health insurance?
4. If yes, how much do you pay for your child's coverage? (Remember, health insurance premiums can include the cost for the employee, the husband or wife and the child or children. If you don't know exactly, an estimate is fine.)
AmountHow often?
Amount
5. Does your child receive services from Birth to 3 Early Intervention?
6. Does your child receive special education services under an IEP?
7. If yes, did the School District ask you
yesno
To enroll your child in Medicaid?
For your permission to bill Medicaid?
8. Does your child receive services through any of these waivers?
yesno
Early Intervention
PFDS
Consolidated
9. Please tell us a little about your family

Counting the child you told us about, siblings and the parents who live with the child, how many people are in your family?
10. What is the family's annual income?
Does your income change from month to month?
Is there anything else you'd like to tell us? (For instance, that you have substantial out of pocket costs that are not reflected in the available answers, that you rely on family members to provide care, etc.)
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