|
Reporting Unit: {{ result.unit_lname }}
Entered By: {{ result.staff_name }}
On: {{ result.time_insert.strftime('%Y-%m-%d') }}
Record ID: {{ result.rec_id }}
|
|
| Identifying Data |
|
| Client Name: {{ client.fname }} {{ client.lname }} |
DOB: {{ client.dob }} |
SSN: {{ client.ssn }} |
Medicaid: {{ client.medicaid }} |
|
| Entitlements Data |
|
| Social Security Recipient: {{ result.social_security }} |
SSI Amount: {{ result.ssi }} |
SSD Amount: {{ result.ssd }} |
| Active Medicaid: {{ result.medicaid }} |
Medicaid Managed Care: {{ result.managed_care }} |
| Medicare Recipient: {{ result.medicare }} |
Medicare ID: {{ result.medicare_id }} |
|
| Public Assistance: {{ result.public_assistance }} |
Public Assistance Amount: {{ result.public_amount }} |
| Section 8: {{ result.section_8 }} |
|
| Private Insurance: {{ result.insurance }} |
Insurance Carrier: {{ result.insurance_carrier }} |
Insurance ID Number: {{ result.insurance_id }} |
|
| Alimony: {{ result.alimony }} |
Child Support: {{ result.child_support }} |
|
| SNAP Recipient: {{ result.snap }} |
SNAP ID: {{ result.snap_id }} |
SNAP Amount: {{ result.snap_amt }} |
| WIC: {{ result.wic }} |
TANF: {{ result.tanf }} |
| Other Non-Cash Benefits: {{ result.other_non_cash }} |
|
| Wages: {{ result.wages }} |
Pension: {{ result.pension }} |
Retirement Income: {{ result.retirement_income }} |
| Other Income: {{ result.other_income }} |
|
| Unemployment: {{ result.unemployment }} |
Workers Compensation: {{ result.workers_comp }} |
|
| VA Disability: {{ result.va_disability }} |
VA Medical: {{ result.va_medical }} |
|
{% endfor %}