Required Documentation
Please provide the following documentation, as applicable, with your completed registration form.
You will be able to upload your documents at the end of the registration form.
Photo I.D. (a Photo I.D. is required for all patients, please provide one of the following)
- Driver's License
- State Identification (I.D.) Card
- Military I.D.
- Passport
- School I.D. (under 18)
- Permanent Resident Card
- Certificate of Citizenship
- Certificate of Naturalization
Insured Patients (Medicaid/Medicare/Private Insurance)
- Current Insurance Card - we need to make a copy of the front and back of your card at each visit.
Proof of Income: Patients may be eligible for discounted services on a Sliding Fee Scale based on household size and income. If you qualify, you will pay a discounted amount for your care at Hope Health. If you wish to be considered for the Sliding Fee Scale, you must submit proof of income. Please see the following guidelines.
- Tax Return (most recent) or Pay Stubs (equivalent to one month)
Weekly = 4 pay stubs |
Bi-weekly = 2 pay stubs |
Semi-Monthly = 2 pay stubs |
Monthly = 1 pay stub |
Additional Income (required if applicable):
- Social Security Income
- Alimony
- Disability Income
- Child Support
- Food Stamps (SNAP) Approval Form - must be the form that shows the household income
Dependents (dependents are only counted if you provide one of the following):
- Tax Return (most recent) with dependent(s) listed
- Birth Certificate
- Marriage License
- Adoption Papers
- Proof of Legal Guardianship