Eligibility

Eligibility

Clinic site use this form to determine if a client qualifies for lab/speciality services.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
MISSION: CATCH serves uninsured residents of the Pikes Peak region who are at or under 200% of the Federal Poverty Level (FPL) and do not qualify for other insurance.

Step 1: Determine if you are within the income guidelines for CATCH services.
Family Size:*
Monthly Income before taxes:*
Annual Income before taxes:*
NOTE: If your income is lower than indicated in the box for your family size, you will need to apply for Medicaid.
If your income is higher than indicated in the box for your family size, you are not eligible to receive CATCH services, but please consult with Clinic staff about other resources.

Family Size	1	2	3	4	5	6
Monthly Income	$1428-$2147	$1931-$2903	$2434-$3660	$2937-$4417	$3440-$5173	$3943-5930
Annual Income	$17,130-$25,760	$23,169-$34,840	$29,207-$43,920	$35,245-$53,000	$41,283-$62,080	$47,321-$71,160

Step 2: Determine your insurance status.
Are you covered by any of these programs? Check all that apply.

MedicaidWorkplace sponsored insuranceMedicarePrivate InsuranceCICP
If no boxes were checked above please check this button to declare:

I am not insured or not eligible for insurance
Please provide copies of these documents to the Clinic site for their CATCH eligibility records:

Proof of local residence -Colorado driver’s license, utility bill with address, lease agreement, voter registration card, etc.

Income proof- last 3 months pay stub for all members in household, Unemployment Benefits, Child Support, Retirement/Pension, Social Security Benefits, SSI Survivor Benefits, SSDI Veterans Benefits, Veteran Widow, Dividends/Interest, Alimony, Loans/Gifts, Workers’ Compensation, Disability Benefits, Financial Aid, Public Assistance, Railroad Retirement, Rental Income, In-Kind Income (working for rent), Other Cash Received Monthly

Notice to Patients: This is to notify you that under Federal law relating to the operation of free clinics, the Federal Tort Claims Act (FTCA), (See 28 U.S.C. §§ 1346(b), 2401(b), 2671-80) provides the exclusive remedy for damage from personal injury, including death, resulting from the performance of medical, surgical, dental, or related functions by any free clinic volunteer health care practitioner, board member, officer, employee, or independent contractor who the Department of Health and Human Services has deemed to be an employee of the Public Health Service. This FTCA medical malpractice coverage applies to deemed free clinic volunteer health care practitioners, board member, officer, employee, or independent contractor who have provided a required or

authorized service under Title XIX of the Social Security Act (i.e., Medicaid Program) at a free clinic site or through offsite programs or events carried out by the free clinic (See 42 U.S.C. §233(a), (o)). The above Federal law and other State and Federal laws including the Federal Volunteer Protection Act of 1997 may cover certain free clinic health care professionals providing health care services to patients at this free clinic.

My signature, below, designates that income and insurance information provided is true and accurate and I acknowledge the FTCA program.
Client Signature*

Clear
Date of Client Signature*

MonthDayYear
Date
Should be Empty: