Questionnaire Text

Questionnaire form view entire document:  text  image
16. Is this person CURRENTLY covered by any of the following types of health insurance or health coverage plans? Mark "Yes" or "No" for EACH type of coverage in items a - h.

c) Medicare, for people 65 and older, or people with certain disabilities
[ ] Yes
[ ] No
Questionnaire instructions view entire document:  text  image
16.Mark the "Yes" or "No" box for each part of question 16.

If the person reports any other type of coverage plan in 16h, specify the type of coverage or name of the plan in the write-in box. DO NOT include plans that cover only one type of health care (such as dental plans) or plans that only cover a person in case of an accident or disability.