|AN 1||AN||1||Today's Date||AP|
|AN 2a||AN||2||a||Last Name||ID|
|AN 2b||AN||2||b||First Name||ID|
|AN 2e||AN||2||e||SSN||If no SSN, write "None"||ID|
|AN 3a||AN||3||a||Email Address||CI|
|AN 3b||AN||3||b||Do you have transportation?||YES; NO||SF|
|AN 4a||AN||4||a||Current Address||CI|
|AN 4b||AN||4||b||Apt #||CI|
How long have you lived in the greater Richmond area?
|___ Years ___ Months||EQ|
Are you traveling in the U.S. on a temporary Visa?
|AN 5c||AN||5||c||Do you:|
(circle one) Own; Rent; Live with family or friends; Live in shelter; Other
|AN 5d||AN||5||d||City/County of Residence||EQ|
|AN 6a||AN||6||a||Home Phone||(Area Code First)||CI|
|AN 6b||AN||6||b||Cell Phone||(Area Code First)||CI|
|AN 6c||AN||6||c||What is your primary language?||English, Spanish, Arabic, Other______||SF, DI|
|AN 6d||AN||6||d||Do you have access to an interpreter?||YES; NO; N/A||SF|
|AN 7a||AN||7||a||Would you say that you are:|
American Indian/Alaskan Native, Asian, Black or African-American, Native Hawaiian/Pacific Islander, White, Other________
|AN 7b||AN||7||b||What is your ethnicity?|
Hispanic or Latino____; Non-Hispanic or Latino
|AN 8a||AN||8||a||Are you|
Married Single Divorced Separated Widowed
|AN 8b||AN||8||b||What is your highest level of education?||DI|
|AN 8c||AN||8||c||Patient ID #||ID|
|AN 8d||AN||8||d||Are you:||Male Female||DI|
|AN 8e||AN||8||e||TG:||MTF FTM||DI|
|AN 9a||AN||9||a||Emergency Contact Name/Relationship:||CI|
|AN 9b||AN||9||b||Emergency Contact Number||(area code first)||CI|
|AN 10a||AN||10||a||Household Information:|
Please list the names and relationships of the patient's family unit living in the house.
|AN 10b||AN||10||b||Name||(ex. John Doe)||HH|
|AN 10d||AN||10||d||Relationship to Patient||(ex. Self, son, wife)||HH|
|AN 10e||AN||10||e||SSN||(If no SSN, write "None")||HH|
|AN 10f||AN||10||f||Head of Household||(as stated on tax return)||HH|
|AN 10g||AN||10||g||Family Members in House||HH|
|AN 11a||AN||11||a||Did you file taxes in the last year?||YES NO||PI|
If NO, did someone else claim you on their return?
If the patient did file taxes last year, and claims a person on their taxes who does not live in their household, please list those persons here:
|AN 13||AN||13||Employment and Insurance Information:|
Please list the patient's work status and insurance information below
|AN 14a||AN||14||a||What is you employment status?|
Full-time, Part-time, Seasonal, Disabled, Retired, Student, Dependent, Unemployed
What is your spouse's employment status?
N/A Full-time, Part-time, Seasonal, Disabled, Retired, Student, Dependent, Unemployed
|AN 15a||AN||15||a||If you are unemployed, for how long?||N/A Yrs:_____ Mos:______||EI, DI|
|AN 15b||AN||15||b||If spouse is unemployed, for how long?||N/A Yrs:_____ Mos:______||EI, DI|
|AN 16a||AN||16||a||Are you a veteran of the United States?||YES NO||DI, ES|
|AN 16b||AN||16||b||If yes, have you applied for benefits?||YES NO||ES|
|AN 16c||AN||16||c||If yes, are you eligible for benefits?||YES NO||ES|
|AN 17a||AN||17||a||What is your place of employment?||N/A||EI|
|AN 17b||AN||17||b||Time Employed There||Yrs:____||EI|
|AN 17c||AN||17||c||Work Phone||(with area code)||EI|
What is your spouse's place of employment?
|AN 18b||AN||18||b||Time Employed There||Yrs:____||EI|
|AN 18c||AN||18||c||Work Phone||(with area code)||EI|
|AN 19a||AN||19||a||Do you have medical insurance?||YES NO||IC, EQ|
|AN 19b||AN||19||b||If YES, what type?||Private, Medicaid, Medicare, Veterans||IC, EQ|
|AN 19c||AN||19||c||Do you have prescription drug coverage?||YES NO||IC|
|AN 19d||AN||19||d||Do you have a VCC Card?||YES NO||IC|
Have you ever applied for Social Security Disability?
|AN 20||AN||20||If YES, date effective:||IC|
|AN 20a||AN||20||a||Have you ever applied for Medicaid?||YES NO||IC|
|AN 20b||AN||20||b||If YES, date effective:||IC|
When and where did you last receive healthcare services?
Is your healthcare the result of an accident?
|AN 22b||AN||22||b||If YES, was the accident work-related?||YES NO||IC|
Do you receive either of the following? If YES, please circle:
|SNAP Benefits General Relief||HI|
|AN 23b||AN||23||b||Income Information|
Please list the amount of income, before taxes, earned by ALL PERSONS in the faimly unit. Include the following types of income: wages/salary/self-employment, child support/alimony, interest/dividends, disability benefits, reitrement benefits, Social Security Income, Unemployment benefits, and any other type of income. Do not include income fro loans.
|AN 23c||AN||23||c||Person Receiving Income||HI|
|AN 23d||AN||23||d||Employer's Name or Source of Income||HI|
|AN 23e||AN||23||e||How Often Do You Receive This?||HI|
|AN 23g||AN||23||g||Total Monthly Income Received||HI|
If no income is received, how do you provide food and shelter for yourself/family?
If no income is received, how do you provide for other daily living expenses (i.e., help with bills, medications, etc.) for yourself/family?
|AN 25a||AN||25||a||Proof of Income Provided:|
Please check which type of proof has been provided to verify income.
|AN 25b||AN||25||b||Pay Stubs # Provided:||PI|
|AN 25c||AN||25||c||1040 Plus Schedules/Year:||Schedule C if self-employed||PI|
|AN 25d||AN||25||d||Letter from Employer||On letterhead||PI|
|AN 25e||AN||25||e||Letter from Social Services Agency||PI|
|AN 25f||AN||25||f||Unemployment Award Letter||PI|
|AN 25g||AN||25||g||Food, Shelter and Support Letter||NOTARIZED||PI|
|AN 25h||AN||25||h||Food Stamp Award Letter||PI|
|AN 26a||AN||26||a||Patient Signature:|
Please have the patient sign the following certification statement.
Patient: I CERTIFY that this information is true and accurate to the best of my knowledge.
I understand that the information is subject to verification. I understand that if my financial situation changes or I obtain health insurance, my eligibility status will need to be re-evaluated. I understand it is my responsibility to notify THE CLINIC f any changes in my financial situation. I authorize the release of my financial records (including Social Security Number) to RX Partnership, pharmaceutical companies and Access Now and/or their agents to determine my eligibility for financial assistance for medicines and verification during routine audits. This review is a check on eligibility only. It is not a guarantee that I will receive benefits from any source, and THE CLINIC offers no such guarantees. I understand that falsification of information submitted will jeopardize my consideration for the program.
|AN 26c||AN||26||c||Signature of Patient:||PC|
|AN 27||AN||27||For Clinic Use Only||CU|
|AN 28a||AN||28||a||Monthly Gross Income||CU, EQ|
|AN 28b||AN||28||b||Annual Gross Income||Projected||CU, EQ|
|AN 28c||AN||28||c||Poverty Level||0-138% ( ) 139-200% ( )|
CU, EQ, FPL
|AN 29a||AN||29||a||Date Reviewed by Screener:||CU|
I certify that based upon the information provided, the individual is eligible for Access Now Services.
|(Name of Screener)||CU|
Identify the reason for Eligibility for Access Now Services (Check all statements that apply):
___Individual is not eligible to enroll in and/or recieve Health Exchange financial assistance.
___Individual/family has been exempted from participating in the Health Exchange
___Individual/family has applied for exemption but not yet received determination
___The individual's income is below 139% of the federal poverty level
___The Clinic Medical Director determined it is in the best medical interest of the patient to receive healthcare services through the Safety Net and Access Now.
Please let us know what medical service(s) you are seeking:
___Behavioral Health Treatment
___Voter Registration Info.
___School or Work Physical
___TB Test Only
|DP 3a||DP||3||a||Last Name||ID|
|DP 3b||DP||3||b||First Name||ID|