ELIGIBILITY APPLICATION

Thank you for your interest in being a patient of the Free Clinic of Culpeper.

Our online application process consists of four parts. Each of the four parts of the application must be submitted for your application to be processed and your screening appointment to be booked.

	ELIGIBILITY APPLICATION
	ELIGIBILITY REQUIREMENTS & AGREEMENT
	MEDICAL HISTORY
	CONSENT AGREEMENTS & PERMISSIONS

Please click NEXT to begin.

ELIGIBILITY FORM
GENERAL CONTACT DETAILS
Please tell us what type of patient you are;*

Previous Patient (Recertification)Prospective / New Patient
How did you hear about the Free Clinic of Culpeper?*

Clinic Outreach StaffFamily / Friend / Current PatientSocial MediaOnline Search [Google, Bing, etc.]Other
Were you last seen more than a year ago?*

YesNo
4-Digit ID Number
Full Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Gender*
Email Address
example@example.com
HOME Phone Number*

Area CodePhone Number
CELL Phone Number

Area CodePhone Number
Physical Address*

Street Address

Street Address Line 2

CityState

Zip Code
Mailing Address (if different)

Street Address

Street Address Line 2

CityState

Zip Code
For proof of residency, you may upload a copy of a (1) VALID ID, (2) LEASE or (3) CURRENT BILL - or - provide a paper hard copy at the time of your screening appointment.

Browse Files
pdf, doc, docx, html, zip, jpg, jpeg, png, gif Cancelof
CONSENT TO CONTACT
Please indicate how we may contact you.
Select all that apply.*

HOME PhoneCELL PhoneEmailText Message
May we leave a message on your HOME phone?*

YesNo
May we leave a message on your CELL phone?*

YesNo
EMERGENCY CONTACT DETAILS
Please provide us with an emergency contact. (i.e. someone that you want the clinic to notify in the event of a life threatening situation).
Emergency Contact Full Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship to Applicant
(i.e. partner, mother/father, son/daughter...)
DEMOGRAPHIC DETAILS
Please provide us with your demographic information to better allows us to understand certain background characteristics of our patients.
What is your marital status?*
What is your highest level of education?*
Would you say you are:*
What is your ethnicity?*
EMPLOYMENT DETAILS
Please provide us with your employment information to better allows us to understand certain employment background of our patients.
What is your Employment Status?*
Are you a Veteran of the United States?*

YesNo
Are you eligible for benefits?*

YesNo
Have you applied for benefits?*

YesNo
How long have you been unemployed?*
(i.e. years / months)
What is your place of employment?*
How long have you been employed?*
(i.e. years / months)
Direct Manager / Supervisor*

First NameLast Name
WORK Phone Number*

Area CodePhone Number
HOUSEHOLD DETAILS
Please provide us with your employment information to better allows us to understand certain employment background of our patients.

	# ADULTS	# DEPENDENTS [claimed on taxes]
Household Size

Please indicate the monthly income YOU receive from;*

	Income ($)
Salary
Cash Income
Social Security Benefits
Child Support
Workers Comp / Unemployment
OTHER

Do you receive either;*

SNAPGeneral ReliefBothNone

Does your spouse receive either;*

SNAPGeneral ReliefBothNone
I, {fullName}, by signing below, understand and agree that;
- All the information on this form is true and accurate to the best of my knowledge.
- All documents provided are genuine and accurate.
- I agree to comply with the terms of eligibility as set forth by the Free Clinic of Culpeper.
- I do not have any health care insurance, including Medicare and Medicaid, or insurance that would provide prescription medication coverage.
- In the event I receive RxPartnership or other IPAP medications, I give my permission for their representative and affiliated pharmaceutical companies to review my medical records for proof of eligibility for audit purposes.
- I agree to notify the Free Clinic of Culpeper immediately of any changes in income, insurance status, or household size.
Signature*

Clear
Date*

MonthDayYear

	Income ($)
Total Monthly Gross Income
Total Annual Gross Income

Signature of Screener

Clear
Date of Screening

MonthDayYear
Date
Certification Good Through

MonthDayYear
Date
Should be Empty:

ELIGIBILITY FORM