SMITH COUNTY INDIGENT
HEALTH CARE PROGRAM
PO Box 7000
Tyler, Texas 75711-7000
SCIHCP APPLICATION/Case No 9705537

Case Name:Christopher A. Walters

The patient named above has applied for SCIHCP. State regulations require that all persons between the ages of 18-50 years who recieve SCIHCP be registered with the Texas employment Commission unless they are physically or mentally incapable of holding gainful employment.

The applicant claims a disability which precludes gainful employment. Any financial charges which result from the completion of this form or from any exam or testing required in the completion of this form are the responsibility of the applicant. Your cooperation in completing the following questions will be appreciated. After completion, please give this letter to the patient who will bring it to us or mail it in the attached envelope.

By: Debra McKeever 5-21-97

Medical information on this report is confidential, becomes the property of, and may be used within the discretion of the SCHICP or shared with other governmetnal agencies to determine eligility for benefits or rehabilitation services. This medical report may become available to the household or the household's represenative for examination up request

To what extent is the patient employable:
Full time, but restricted too Checked no heavy work

PROGNOSIS: Good

How long will patient be disabled from work? (approximate number of months, if not permanent.... 2 weeks

Physicial Signature Donal W. Steph Date 5/23/97
1015 E Idel, Tyler, Texas 75701
From Dr. Fleisher, MD

TO: Christopher Alan Walters Date: 5-21-97
% Salvation Army SMITH COUNTY
717 N Spring Street Case Number: 9705537
Tyler, Texas 75702 DOB: 10-17-50
Note: SSI/SSDI Appellant-No

Your application for County Indigent Health Care Program Benefits is approved. You are eligible for medical services beginning 5-20-97

Please show this letter each time you request medical services:

* The only pharmacy you can use is Craig Pharmacy, 1406 S Fleishel, Tyler Text. Your case Review date is no later than: 10-31-97 This program is not responsible for medical expenses incurred after the review date, unless eligility is re-established when your case is reviewed. Note: Medical Claims received more than 95 days (1) after the Indigent Health Care Certification date; or, (2) more than 95 days after the services are rendered are not eligible for payment by this program.

By/ Debra McKeever
Smith County Indigent Medical Health Care Officer

Your Responsibilities

You must notify this office within 14 days of any changes in your situation, such as changes in your income, property, household members, child care expense, address, SSI, SSI Application, or SSI, SSD decision. If a change occures that makes you ineligible, and you fail to report the change as required, you may be held responsible for payment of any medical service you recieve after you become ineligible or you may be subject to prosecution under Texas Penal Code***Should you apply for SSI,SSD, provide a reciept.

Mail Medical Claims Too:Indigent Health Care
Attn: Bookkeeper
PO Box 7000
Tyler, Texas 75711-7000
(903-531-8361)