Patient Eligibility Application


Contact Information

Date of Birth*

MonthDayYear
Social Security Number [SSN]*
If no SSN, write "None"
HOME Phone Number*
Please enter a valid phone number.
CELL Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Physical Address*

Street Address

Street Address Line 2

CityState

Zip Code
County of Residence*
How long have you lived in our service area?
Current Living Situation*

OwnRentLive with family or friendsLive in ShelterOther


Household Information

Please list the names and relationships of those you are financially responsible for - i.e. everyone listed on your tax form.*

Did you file taxes in the last year?*

YesNo
If you claimed a person who does not live in your household, please list them here:
Did someone else claim you on their tax return?*

YesNo
Please list the name and relationship of who claimed you in their taxes:
You may upload your tax documents here – or you will need to bring copies to your screening appointment. [Note: Taxes must be signed and dated by person(s) filing taxes]

Files may be loaded as pdf, doc, docx, html, zip, jpg, jpeg, png, and/or gif
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I, {fullLegal}, certify that the information herein is an 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 FREE CLINIC OF POWHATAN of any changes in my financial situation. I authorize the release of my financial records (including Social Security Number) to RX Partnership, CrossOver, 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 FREE CLINIC OF POWHATAN offers no such guarantees. I understand that falsification of information submitted will jeopardize my consideration for the program.
Please upload a copy of your ID card – state issued license or ID card, federal ID card, passport, consular ID, permanent resident ID, etc.

Files may be loaded as pdf, doc, docx, html, zip, jpg, jpeg, png, and/or gif
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Signature of Patient [use your mouse, track pad or finger on touchscreen]*

Clear
Submission Date*

MonthDayYear
Should be Empty:

	Name of Person Receiving Income	Relationship to Patient	Source of Income	Frequency	Amount
1
2
3
4
5
6


Dental Patient - Intake
As a prospective patient to our Dental Services, please complete the following questions as part of our dental intake.


Pre-Screening Information


Demographic Information


Employment Information