Patient Qualification Application
Language
  • English (US)
  • Español

  • Patient Qualification Application

     

    When your application is received by our clinic you will get an email confirmation. If you do not get a confirmation email, please resubmit your application. If you have submission concerns please email qualify@vimjax.org.

     

    If you are a current VIM patient, please do not fill out this application. This application is for new applicants ONLY. Exisiting patient or those who have been seen by VIM in the past year must complete the Patient Re-Qualification Application to requalify for the upcoming year. Filling out this application will delay your requalification and may cause you to become inactive with our clinic. If you have questions or concerns, please email requalify@vimjax.org. 

  • Are you or your spouse/partner currently working?*

  • To become a patient at our clinic you OR your spouse/partner must be working and able to provide income documentation. If both are unemployed do not complete this application, instead, please submit an inquiry at JaxCareConnect. JaxCareConnect will be able to connect you with appropriate resources in the community. 

  • Do you currently have any form of health insurance, even if you do not use it, or only use it for things like medication?*

  • We do not accept applicants who currently have health insurance coverage. If you have health insurance do not complete this application, instead, please reach out to Agape Family Health, Sulzbacher Center or your health insurance provider for assistance. 

  • Do you have any of the following?*

  • We do not accept applicants who currently have health insurance coverage. If you have health insurance do not complete this application, instead, please reach out to Agape Family Health, Sulzbacher Center or your health insurance provider for assistance. 

  • Have you ever been seen by Volunteers in Medicine?*
  • Do you live in Duval County?*
  • Are you being referred by JaxCareConnect?*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  •  / /
  • Volunteers in Medicine provides free medical treatment to all patients, regardless of country or immigration status. Are you a US citizen?*
  • Are you a Veteran?*
  • Gender*
  • Race (Check all that Apply)*
  • Ethnicity*
  • Preferred Language*
  • Will you require a language translator for your medical appointments?*
  • Which Volunteers in Medicine location does the patient plan to visit?*
  • Does the address listed on this application match the address listed on your identification?*
  • Format: (000) 000-0000.
  • What brings you to Volunteers in Medicine (VIM)?*
  • Do you have any medication that you need a refill for OR have you been told you need a medication by a medical professional?*
  • How did you learn about VIM?*

  • Financial Qualification Information

  • Who is working in your household?*

  • To become a patient at our clinic you OR your spouse/partner must be working and able to provide income documentation.

    If both unemployed do not complete this application,

    please submit an inquiry at JaxCareConnect, who will be able to connect you with the appropriate resources in the community.

  • Please fill out the information below for you and your spouse/partner's pay info. 

     

    All fields must be filled out. The form will not submit if any fields are left blank. 

     

    If you are not working but your partner or spouse is, please list N/A under your info and enter 0 for pay, hours, and phone number

    If you do not have a partner or spouse, please leave that section blank

  • Your Employer:      *              
    Your Employer Phone:   *   * 
    Your Pay Rate:      *   
    Average hours worked per week:   *   
    How often are you paid?         
                

  • Your Partner's Employer:                    
    Your Partner's Employer Phone:       
    Your Partner's Pay Rate:         
    Average hours worked per week:      
    How often are they paid?         
                

  • Please see financial guidelines above. 

    In order to qualify for our services we require applicants to provide financial documentation of CURRENT INCOME IN THE LAST 4 WEEKS,

    FAILURE TO SUBMIT CORRECT DOCUMENTATION WILL DELAY THE APPLICATION PROCESS AND WE WILL NOT BE ABLE TO QUALIFY YOU 

    All household income documentation needs to be provided, even if your spouse/partner is not qualifying to be a patient with us.  

     Proof of income can be any or all of the following:

    • Most recent 1 month worth of pay stubs WITH YOUR NAME ON THEM
    • A signed letter from your employer stating hours worked and pay rate on company letterhead
    • Child support documentation, food stamps / EBT documentation
    • DO NOT SUBMIT W-2s, 1099s, tax returns, or screenshots of pay apps

    If self-employed, please upload any or all of the following:

    • Most recent 3-6 months of bank statements
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Emergency Contact:   *   *
    Relation:    *   Phone:   *   *

  • Before you applied to Volunteers in Medicine, what did you do for care when you were sick?*

  • Qualifying Health and Social Determinants of Health Questionnaire

  • Do you have a history of or have you ever been diagnosed by a medical provider as having bipolar disorder?*

  • Are you taking medication for this condition?  . List the medication here: . What was the date of your last dose?   Pick a Date.

  • Have you ever been diagnosed by a medical provider as having schizophrenia?*

  • Unfortunately, VIM is unable to accept patients who are living with acute mental health conditions that require frequent monitoring. We recommend seeking care through JaxCare Connect to ensure the best care possible.

  • Have you ever been diagnosed with a seizure disorder?*
  • Are you on or have you ever been on dialysis?*
  • Have you ever had an organ transplant?*
  • Do you see a neurologist for any reason other than headaches, or numbness due to diabetes*
  • Do you currently need to have surgery for any reason other than a breast mass?*
  • Have you been told you have cancer, a lump, mass or nodule (other than in the breast) that you need a special test for?*
  • Do you have sickle cell anemia?*

  • Because sickle cell anemia is a genetic condition diagnosed in early infancy that requires frequent hospitalizations for pain management, we encourage you to reach out to JaxCare Connect to ensure the best care possible.

     Note: VIM can accept patients with anemia, also known as low iron, as well as those with sickle cell trait.

  • Are you living with HIV/AIDS?*

  • Due to the complexity of treatment for those living with HIV/AIDS, we encourage you to connect with JaxCare Connect to ensure the best care possible, as our clinic does not treat those living with HIV/AIDS.

  • Are you pregnant?*

  • Volunteers in Medicine does not offer prenatal care. After your pregnancy we invite you to reapply to our clinic! In the meantime, we encourage you to reach out to JaxCare Connect to ensure the best care possible

  • What is your living situation today?*

  • If you are experiencing homelessness or have insecure housing, we encourage you to reach out to 211 by dialing "211" to access housing resources in your area

     

  • Please describe your tobacco/nicotine use (such as cigarettes, e-cigs, mods, pod devices like JUUL, disposable vapes like Puff Bar, vape pens, or e-hookahs, cigars, cigarillos, hookahs, chewing tobacco, snuff, snus, dissolvable, or nicotine pouches):*
  • Is it okay that we connect you with the Volunteers in Medicine Tobacco Cessation Lead who will provide you free support/resources to quit nicotine/tobacco?*
  • Nutrition Security Screening Question 1: "We worried whether our food would run out before we got money to buy more.” Was that often true, sometimes true, or never true for your household in the last 12 months?*

  • We are providing the below local food pantry resources based on your responses to the nutrition screening questions in the Volunteers in Medicine New Patient or Requalifying Patient Application.

     


    https://feedingnefl.org/find-food-now/

     

    First Coast Recovery Advocates, (904) 580-4538

    Community Health Outreach, (904) 573-1333

    Old Plank Baptist Church's Food Pantry, (904) 783-6942

    Vinekeepers' Food Pantry, (904) 412-6175

  • Nutrition Security Screening Question 2: "The food we bought just didn’t last, and we didn’t have money to get more.” Was that often true, sometimes true, or never true for your household in the last 12 months?*

  • We are providing the below local food pantry resources based on your responses to the nutrition screening questions in the Volunteers in Medicine New Patient or Requalifying Patient Application.

     


    https://feedingnefl.org/find-food-now/

     

    First Coast Recovery Advocates, (904) 580-4538

    Community Health Outreach, (904) 573-1333

    Old Plank Baptist Church's Food Pantry, (904) 783-6942

    Vinekeepers' Food Pantry, (904) 412-6175

  • Are you currently receiving WIC/SNAP(food stamps) benefits?*
  • Do you give us permission to connect you with a local organization representative to assist you with the SNAP/WIC application process?*

  • Please send email to:  Francine.Brooks@bmcjax.com  and  CC jarvispaul.ramil@bmcjax.com to assist you with the SNAP/WIC application process. Pleae include your name email and phone number in the email so they can connect with you and begin the applicatation process. 

     

  • I understand that Volunteers in Medicine Jacksonville neither prescribes narcotics/controlled substances nor keeps them on the premises.*
  • In the event that we determine that you do not qualify for our services, we will give your name and contact information to JaxCareConnect on your behalf, so that they can link you with other resources. Please select an option below to grant or deny us permission to do so.*

  • We want to do our best to help you in a timely manner, so after you hit submit below, a window will pop up with a button to schedule your eligibility phone call with us.

    NOTE: IT COULD TAKE UP TO 2 MINUTES (WITH BLANK SCREEN) for the Thank You Page to pop up. This is normal. After Thank You Page appears, you'll see the link to schedule your qualification call with us, where you will pick a date/time that works for you! Please be patient here. Thank you

  • Schedule your Qualification Call

    This phone call will be used to determine if you qualify with us. If you do qualify, we will schedule your first medical appointment. If you do not qualify, we will use this call to connect you with other resources in the community. We will call you at the scheduled appointment time. Please note that we will call the "Primary Phone Number" you provided above.

  • You are scheduling a phone appointment to discuss eligibility. The below is not a medical appointment. 

  •  

  • If you click "Submit"  and the form does not respond, scroll up to see errors in red that need to be fixed before you can submit. If you have any issues submitting this form please call 904-399-2766 or email qualify@vimjax.org and provide a phone number where you can be reached. 

  • Should be Empty: