Patient Qualification Application

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

YesNoUnsure/Comment

Are you taking medication for this condition? Yes No. List the medication here: . What was the date of your last dose? Date.

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

YesNoUnsure/Comment

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?*

YesNoUnsure/Comment

Are you on or have you ever been on dialysis?*

No, I have NEVER been on dialysisYes, I am CURRENTLY on dialysisYes, I PREVIOUSLY was on dialysisI was told that I needed to get on dialysis but never did

Have you ever had an organ transplant?*

YesNoI was told by a doctor that I needed one, but have not had surgery

Do you see a neurologist for any reason other than headaches, or numbness due to diabetes*

YesNoUnsure/Comment

Do you currently need to have surgery for any reason other than a breast mass?*

YesNoUnsure/Comment

Please describe in as much detail as possible below.

Have you been told you have cancer, a lump, mass or nodule (other than in the breast) that you need a special test for?*

YesNoUnsure/Comment

Do you have sickle cell anemia?*

YesNoUnsure/Comment

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?*

YesNoUnsure/Comment

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?*

YesNoUnsure/Comment

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?*

I have a steady place to livehave a place to live today, but I am worried about losing it in the future.I do not have a steady place to live (I am temporarily staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, abandoned building, bus or train station, or in a park)Decline to answer

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, dissolvables, or nicotine pouches):*

CurrentFormerNever

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?*

YesNo

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?*

Often trueSometimes trueNever truePrefer not to answer

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?*

Often trueSometimes trueNever truePrefer not answer

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?*

YesNoPrefer not to answer

Do you give us permission to connect you with a local organization representative to assist you with the SNAP/WIC application process?*

YesNo

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.*

YesNo

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.*

I AUTHORIZE Volunteers in Medicine Jacksonville to give my name and contact information to JaxCareConnect on my behalf.I DO NOT AUTHORIZE Volunteers in Medicine Jacksonville to give my name and contact information to JaxCareConnect on my behalf.

Patient Signature, signing that you have answered the above information to the best of your knowledge.

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.

Financial Qualification Information

Qualifying Health and Social Determinants of Health Questionnaire