MFC Patient Application Form

New Patient/Renewal Application Form

To qualify, you must be an uninsured adult living in Madison County, Virginia, with household income equal to or less than 300% of the Federal Poverty level. If your household income is equal to or less than 138% of FPL, AND you are under age 65, you must also apply for Medicaid through the State of Virginia. For those who qualify, Medicaid provides more comprehensive coverage than the Free Clinic can offer. Our volunteers are trained to assist you with your Medicaid application if needed. Please check your eligibility at https://coverva.org/

NOTE: if you have no income and are not required to file taxes, please have the person who covers your expenses (i.e., food, rent) complete this letter of support.

If you need help completing this form, please contact our office by phone at 540-948-3667 or by email to intake@madisonfreeclinic.org

How did you hear about the Madison Free Clinic?

Postcard Newspaper article TV story Word of Mouth Search engine (Google, etc.) Facebook

Is this a new application, or are you renewing your card? *

New Renewal

Name of patient as you would like it to appear on your health records *

First Name Last Name

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Do you currently have any form of health insurance? *

Medicare Medicaid Employer or private insurance None

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

What services do you need help with (check all that apply)? *

Medical Dental Non-narcotic prescriptions Vision

Please describe any medical issues you are currently experiencing

Email

example@example.com

Current age *

Date of Birth *

Date

Last 4 digits of Social Security number *

Do you think of yourself as *

Straight or heterosexual Lesbian or gay Bisexual Queer, pansexual, and/or questioning Don't know Decline to answer

Do you think of yourself as *

Male Female Transgender man/trans man/female-to-male (FTM) Transgender woman/trans woman/male-to-female (MTF) Genderqueer/gender nonconforming/neither exclusively male nor female Decline to answer

What sex were you assigned at birth? *

Male Female Decline to answer

What are your pronouns? *

He/him She/her They/them

Marital status *

Single Married Separated Divorced

Is the patient of Hispanic, Latino, or Spanish origin? *

No, not of Hispanic, Latino, or Spanish origin Yes, Mexican, Mexican American, Chicano Yes, Puerto Rican Yes, Cuban Yes, another Hispanic, Latino or Spanish origina such as Salvadoran, Dominican, Columbian, Guatamalan, Spaniard, Equadorian, etc.

Race

American Indian or Alaska Native Asian Black or African American Native Hawaiian and Pacific Islander White Some other race

Best phone number to contact patient *

Area Code Phone Number

Can the phone number provided receive text messages?

Emergency contact name

Emergency contact phone number

Household size (Tax filer + spouse, if married + tax dependents = household size) *

Names and ages of any dependents listed on your tax return

Name of spouse (if married)

Did you file a State or Federal tax return last year? *

Yes No

Do you expect to file a State or Federal tax return this year? *

Yes No

Patient's monthly income *

If married, spouse's monthly income

Have you applied for financial assistance from UVa? *

Yes No

Is there anything else you'd like to know?

Please upload the following documentation: 1.) a copy of your ID (i.e., driver's license, state or school ID, voter registration card), 2.) proof of residence (i.e., utility bill, bank or credit card statement) and 3.) proof of income (i.e., paystub, tax return, unemployment benefit form) OR 4.) a signed letter of support from a friend or family member that states that they cover your living expenses (food, shelter, etc.).

Upload or attach these files or pictures

Trouble uploading or attaching files? You may email them to intake@madisonfreeclinic.org. Need more help? Please give us a call at 540-948-3667

I hereby grant the Madison Free Clinic permission to verify and discuss my medical and financial information with those directly involved with my care, i.e., physicians, pharmacists, and others as directly relates to my care. Any other request for medical information will require my prior authorization. I hereby grant the Madison Free Clinic permission to share my name and demographic information (i.e., age, marital status) to the Virginia Department of Social Services and other agencies that may be able to provide me with additional assistance. By typing my name and today's date in the space below, I hereby certify that the information I have provided is true and complete. *

FOR OFFICE USE ONLY