Patient Qualification Application

Patient Qualification Application
Please Enter Your Legal Name

First NameMiddle NameLast Name
Are you or your spouse/partner currently working?*

YesNo
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?*

YesNo
VIM will run an insurance verification check on every applicant and patient during requalification. I understand VIM will run an insurance verification check using my information.*

Clear
Do you have any of the following?*

AmBetterSunshine HealthShand's CardMedicaidMolinaFlorida BlueAetnaUnited HealthCareI have something elseI do not have any of these
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?*

YesNo
Do you live in Duval County?*

YesNo
Are you being referred by JaxCareConnect?*

YesNo
In order to receive certain treatment/services our patients must be Duval County residents. Though we recommend that you connect with a resource in your county, we do not require you to be a Duval County resident to apply to become a patient with us.
Patient's Full Legal Name*

First NameMiddle NameLast Name
Please upload a picture of your Photo ID

Cancelof
Date of Birth*

MonthDayYear
Our clinic serves patients ages 18-64.
Volunteers in Medicine provides free medical treatment to all patients, regardless of country or immigration status. Are you a US citizen?*

YesNo
Social Security Number
NOTE: This form is HIPPA compliant + secure. It will speed things up by entering it now, however you can opt to skip this question.
Are you a Veteran?*

YesNo
Gender*

MaleFemaleTransgender Man (female-to-male)Transgender Woman (male-to-female)Non-Binary
Race*

WhiteAfrican AmericanAsianAmerican Indian / Alaska NativeNative Hawaiian / Pacific IslanderOther
Ethnicity*

Non-HispanicHispanic
Preferred Language*

EnglishSpanishFrenchOther
Will you require a language translator for your medical appointments?*

YesNo
Which Volunteers in Medicine location does the patient plan to visit?*

South San Marco ( 3728 Philips Highway Suite 34, Jacksonville, FL 32207)West Jax (5927 Old Timuquana Rd, Jacksonville, FL 32210)
Patient's Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Primary Phone Number*
Please enter a valid phone number.
Email*
example@example.com
What brings you to Volunteers in Medicine (VIM)?*

DiabetesHypertensionAnnual CheckupSexual Health ScreeningOther
How urgent would you consider a visit to the doctor?

Very UrgentUrgentSomewhat UrgentNot Urgent
How did you learn about VIM?*

Community Event/Peace ProgramGoogle SearchReferral by friend/family memberOther
Financial Qualification Information
Who is working in your household?*

I am the only one who is workingMy spouse/partner is the only one who is workingMy spouse/partner and I are both workingNeither my partner/spouse or myself are working
Please select ALL of the following that are true:*

I am currently workingI am NOT currently workingI live with a spouse/partner who is currently working.I live with a spouse/partner who is NOT currently working -OR- I do NOT live with a spouse/partner
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, instead, please submit an inquiry at JaxCareConnect, who will be able to connect you with the appropriate resources in the community.
Are you or your spouse/partner currently working?*

YesNoOther/Comments
Your Employer:      Business Name*
Your Employer Phone:   Area Code*   Phone Number*
Your Pay Rate:      *
Average hours worked per week:   *
How often are you paid?   Example: "twice a month, once a month"
Hourly Employee   Salaried Employee   Self-Employed   Other
Your Partner's Employer:      Business Name
Your Partner's Employer Phone:   Area Code   Phone Number
Your Partner's Pay Rate:
Average hours worked per week:
How often are they paid?   Example: "twice a month, once a month"
Hourly Employee   Salaried Employee   Self-Employed   Other
Your Spouse/Partner's Name:   First Name   Last Name
Your Spouse/Partner's Date of Birth:   Date
Is your spouse/partner a current Volunteers in Medicine patient?   Yes   No
Your Spouse/Partner's Employer:      Business Name
Your Spouse/Partner's Supervisor:   First Name   Last Name
Your Spouse/Partner's Employer Phone:   Phone Number
Your Spouse/Partner's Pay Rate:
Average hours worked per week:
How often is your spouse/partner paid?   Example: "twice a month, once a month"
Hourly Employee   Salaried Employee   Self-Employed   Other
Are you or your spouse/partner self-employed?*

YesNo
How many people are in your household? Household is defined as your spouse/partner and any legal dependents under your care.*
Applicant + Partner/Spouse + Legal Dependents (If you are the only person in the household, you will answer "1")
Household Member and Date of Birth
Example: John Smith, 08/14/1987
Household Member and Date of Birth
Example: John Smith, 08/14/1987
Household Member and Date of Birth
Example: John Smith, 08/14/1987
Household Member and Date of Birth
Example: John Smith, 08/14/1987
Household Member and Date of Birth
Example: John Smith, 08/14/1987
Household Member and Date of Birth
Example: John Smith, 08/14/1987
Household Member and Date of Birth
Example: John Smith, 08/14/1987
Household Member and Date of Birth
Example: John Smith, 08/14/1987
Please see financial guidelines above.

In order to qualify for our services we require applicants to provide financial documentation of CURRENT INCOME, typically via pay stubs from an employer. All household income documentation needs to be provided, even if your spouse/partner is not qualifying to be a patient with us. If your spouse/partner works, you will need to attach their pay stubs in addition to yours below.

Proof of income can be any or all of the following:
- Most recent 1 month worth of pay stubs
- 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, or tax returns
If self-employed, please upload any or all of the following:
- Most recent 3-6 months of bank statements
If you receive mobile statements, please upload your full paystub that includes your name.
Click "Browse Files" below to attached proof of income below. Please make sure that all attachments/pictures are clear/legible. Pay information without full names will significantly delay the qualifying process.*

Files accepted: pdf, doc, docx, xls, xlsx, csv, txt, rtf, zip, jpg, jpeg, png,
Cancelof
Please provide any helpful details regarding the income documents you uploaded above.
I certify that the financial information is correct. The person listed as my partner/spouse is correct and all of the people above are living at the same address.*

Clear
Emergency Contact: First Name* Last Name*
Relation: * Phone: Area Code* Phone Number*
Before you applied to Volunteers in Medicine, what did you do for care when you were sick?*

Went to the ERWent to Urgent CareWent to Family DoctorI'm not sureIgnored that I was 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?*

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
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
Are you living with HIV/AIDS?*

YesNoUnsure/Comment
Are you pregnant?*

YesNoUnsure/Comment
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 ashelter, living outside on the street, on a beach, in a car, abandoned building, bus ortrain station, or in a park)Decline to answer
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.

Clear
Please use the calendar below to select a time for a qualifying volunteer to speak with you about your application. You will be able to schedule a medical appointment with our clinic at that time. *
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.

Please note: if you need to speak with a volunteer who speaks Spanish, please select a Saturday appointment. We hope to provide additional appointment opportunities for our Spanish speaking applicants very soon, sorry for the inconvenience.
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. You may also qualify over the phone by calling 904-399-2766.
Should be Empty:

Financial Qualification Information

Qualifying Health and Social Determinants of Health Questionnaire