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ORAL HEALTH
Benefits Access Survey
ASIDE FROM providing information and referral services, please indicate which of the following benefits your organization either
helps consumers access (eg. application assistance) OR provides the
service directly.
*
Indicates required field
Organization:
*
Name:
*
First
Last
PLEASE INDICATE ALL THAT APPLY. IF YOU ARE NOT CERTAIN, DO NOT CHECK.
1. FOOD ASSISTANCE
*
Food Stamps (Bridge Card)
Congregate Meals - Nutrition
Double Up Food Bucks
Home-Delivered Meals
Project Fresh
Other:
(provide additional information here)
*
2. TRANSPORTATION
*
DDOT - Senior Pass
Assistive Transport Services
Metro Lift
SMART
Other:
(provide additional information here)
*
3. HOUSING
*
Section 8
Other:
(provide additional information here)
*
4. HEALTHCARE
*
Federally Qualified Health Clinic
Medicare
Medicaid Savings Plan
Medicaid Cash Assistance
Veteran's Health Benefits
MI RX Card
Veteran Administration's Health Care System
Healthcare Navigation
Other:
(provide additional information here)
*
5. HOME SUPPORTS
*
Home Care Assistance
Home Chores
Other:
(provide additional information here)
*
6. HOME OWNERSHIP
*
Property Tax Relief
Veterans Home Assistance
Weatherization
Other:
(provide additional information here)
*
7. UTILITY
*
Home Heating Tax Credit
Low Income Home Energy Assistance Program (LIHEAP)
Other:
(provide additional information here)
*
8. LEGAL/MEDICAL AFFAIRS - MANAGEMENT
*
Guardian (PERS)
Other:
(provide additional information here)
*
9. INCOME ASSISTANCE
*
Low-Income Subsidy
Social Security - Retirement/Survivors
Social Security - Disability
Supplemental Security Income (SSI)
Retirement Pension
Temporary Assistance to Needy Families (TANF)
VA Compensation
Railroad Retirement Program
Federal Retirement Program
Volunteer Stipend
Workmen's Compensation
Unemployment Benefits
State Emergency Relief (SER)
Other:
(provide additional information here)
*
10. EMPLOYMENT
*
Senior Community Service Employment Program (SCSEP)
Work Income/Employment
Other:
(provide additional information here)
*
11. NURSING HOME & LONG TERM CARE ISSUES
*
Veterans HOME Program
Nursing Home Medicaid - Spousal Impoverishment
Mi Choice Waiver Program
Other:
(provide additional information here)
*
Submit
