INCOME INFORMATION
WHY DO I NEED TO PROVIDE MY PAY STUBS (3) AND A RECENT TAX RETURN?
1. To determine eligibility for services.
2. CHC can provide assistance in acquiring medications at a free or reduced cost. Many drug manufacturers have Prescription Assistance Programs (PAP).
ALL of the drug manufacturers who offer PAP require income verification.
* To request a copy of your tax return, complete IRS form 4506 or call
1-800-908-9946
DECLARATION OF NO INCOME
(Complete this section if you have no household income)
I, First Name Last Name confirm to the fact that I do not and have not received any income in the past three months. This includes wages from employment or self-employment, alimony, cash assistance, child support, pension, social security, unemployment and/or workers compensationI certify that this information provided is complete and accurate to the best of my knowledge. I understand that the services provided by the Community Health Center are based on income guidelines. I understand that upon employment or receipt of any income, I must submit proof of income to the Community Health Center.
Who was your previous primary care physician? Name/Location of Physician, If None, type "NONE"* Date last seen? Date
Name of behavioral health facility Name/Location of Facility
(including prescriptions, aspirin, vitamins, supplements, herbal remedies and over-the-counter medications)
PLEASE BRING ALL CURRENT PRESCRIPTIONS TO YOUR INITIAL MEDICAL APPOINTMENT
Medication - if None, type "0"* Medication Medication Medication Medication Medication Medication
PREFERRED PHARMACY Name/Location of Pharmacy, If None, type "NONE"*
(List all allergies, including allergies to medications)
Allergy - if None, type "0"* Allergy Allergy Allergy
How many packs per day? Number* How long have you smoked? years*
How many drinks per week? Number*
When was your last eye exam? Year*
How many cups per day? Number*
When was your last dental exam? Year*
(Current and Past Medical Conditions)
If you've had a Stroke, please specify date. Date, if None, type "NONE"* If you've had Cancer, please specify type. Type, if None, type "NONE"* If Other, please specify condition. Condition, if None, type "NONE"*
(Please enter TYPE and YEAR of each Surgery, if None, type "NONE")
What Year was your most recent:
PAP Date, if None, type "NONE"* Mammogram Date, if None, type "NONE"* Lab Work Date, if None, type "NONE"* Colonoscopy Date, if None, type "NONE"* EKG Date, if None, type "NONE"*
(Relationship: Mother, Father, Brother, Sister, Paternal/Maternal Grandmother or Grandfather, Paternal/Maternal Aunt or Uncle)
I hereby request and consent to the rendering of health care by the Jean B. Purvis Community Health Center (CHC). I understand that this clinic is staffed by a health care team which may include volunteer physicians, dentists, nurse practitioners, nurses, technicians and other volunteers. I freely accept care from this health care team and acknowledge the establishment of the provider/patient relationship. I further understand that this health care team will provide information and/or care; however, I maintain the right to make all decisions regarding my health care.
I understand that CHC may obtain medications for my treatment through Patient Assistance Programs (PAP) sponsored by major pharmaceutical companies. If I meet eligibility requirements for PAP, I authorize the CHC Medical Director or designee to sign my name on the medication order form. My name will only be signed on medication orders specifically for me as prescribed by my health care provider.
This consent is to remain in effect until it is revoked by me in writing.
I authorize CHC to verbally communicate my medical information with the following individuals. The individuals listed below are also given permission to pick up my medications from the CHC if I am unable to pick them up in person.
By signing below, I acknowledge the following: