JEAN B PURVIS COMMUNITY HEALTH CLINIC APPLICATION FOR SERVICES

JEAN B PURVIS COMMUNITY HEALTH CENTER OF BUTLER COUNTY
The Community Health Center (CHC) IS NOT INSURANCE. All services provided by CHC are FREE. CHC is Volunteer-Powered and Community-Funded. CHC does not provide emergency care. Applications are required to determine eligibility for services and MUST be completed before any appointments will be scheduled.

Eligibility Requirements:

- Age 19-64

- Uninsured or Underinsured

- Have a countable household income below 300% of the Federal Poverty Income Guidelines (listed below)

**Household is defined as applicant, spouse, and dependents

- Not currently seeing physicians for the services requested

**Ex. Having a PCP but requesting medical services

(We do not duplicate services)

Income Information

If you have current employment, you MUST fill this portion out entirely.
CHC defines "household" as the applicant, spouse, and dependents.

If SINGLE, please list your income only. If you have children, please indicate the # of children as well as the total # in the household.

If MARRIED, please list your and your spouse's income. If you have children, please indicate the # of children as well as the total # in the household.
Total # in Household*
Total # in Household*
# of Adults*
# of Adults*
# of Children (under 18)*
# of Children (under 18)*
Total Household MONTHLY Income*
Total Household MONTHLY Income*
Did you file a tax return last year?*

YesNo
Tax return attached?*

YesNo
All patients seeking treatment at the Community Health Center are REQUIRED to submit proof of income, when applicable. This information is needed to determine eligibility for the Community Health Center and is needed for any Prescription Assistance Program (PAP) applications. You selected NO on the tax return attached question.

Please read the following bullets from the Patient Statement of Understanding (A copy of the Patient Statement of Understanding is provided at the end of the application.)

- I understand that I am required to provide the following documentation by my SECOND VISIT: photo ID, proof of household income, and a copy of my most recent tax return. Income documentation and tax returns will be used to determine my eligibility for services at CHC and are required on a yearly basis to continue services at CHC. I am required to update CHC with any changes to my income and/or status of medical insurance

- I understand that failure to provide the documentation listed above by my second visit will result in services being POSTPONED until I provide the requested documentation.

The documents can be submitted in four (4) ways.

1. email: info@butlerhealthclinic.org

2. Mail: 103 Bonnie Drive, Butler, PA 16002

3. Fax: 724-841-0984

4. Bringing the documents to your first appointment

Your application will be reviewed for eligibility, but you are still required to bring in all documentation listed above if applicable. Please sign and date below, acknowledging you have read this notice and understand your responsibility.
Signature*

Clear
File Upload*

Cancelof
* To request a copy of your tax return, complete IRS form 4506 or call 1-800-908-9946

Why do I need to provide my pay stubs and tax returns? To determine eligibility for services and CHC can provide assistance in acquiring medications at a free or reduced cost. Many drug manufacturers have Prescription Assistance Programs (PAP) ALL of the drug manufacturers who offer PAP require income verification.
Members of the Household

Please identify all members of your household and all sources of household income. CHC defines "household" as the applicant, spouse, and dependents.
Name*
Date of Birth
Source of Income *
Amount (Monthly Gross)*
Name
Date of Birth
Source of Income
Amount (Monthly Gross)
Name
Date of Birth
Source of Income
Amount (Monthly Gross)
Name
Date of Birth
Source of Income
Amount (Monthly Gross)
Name
Date of Birth
Source of Income
Amount (Monthly Gross)
DECLARATION OF NO INCOME

This portion is required if you currently have no income from any sources.
I confirm to the fact that I do not and have not received any income in the past three months. This includes wages from employment or self-employment, alimony, cash assistance, child support, pension, social security, unemployment, and/or workers compensation.

I certify that this information provided is complete and accurate to the best of my knowledge. I understand that the services provided by the Community Health Center are based on income guidelines. I understand that upon employment or receipt of any income, I must submit proof of income to the Community Health Center.
Print Name*
Signature*

Clear
Date*

MonthDayYear
Date

NO SHOW POLICY

It is imperative that all patients seeking services at the Community Health Center adhere to our no-show policy, which we strictly monitor and manage. Our providers are volunteers who selflessly offer their time to serve the community, and it is essential that you respect their time by canceling appointments in advance. The policy is in place to ensure that we can offer timely access to all our patients, and we expect your cooperation in this regard. Below is our no-show policy for the Community Health Center.

The CHC requires at least 24 hours' notice to cancel any appointment

You may do so by calling 724-841-0980 or emailing info@butlerhealthclinic.org

New patients must attend all scheduled appointments. Failure to attend two (2) appointments without prior notice will result in immediate dismissal from the clinic.
Please initial below acknowledging that you have read and fully understand the CHC's NO SHOW POLICY.*

Consent to Treatment
I hereby request and consent to the rendering of health care by the Community Health Center (CHC). I understand that this clinic is staffed by a health care team which may include physicians, dentists, nurse practitioners, nurses, technicians, and other volunteers. I freely accept care from this health care team and acknowledge the establishment of the provider/patient relationship. I further understand that this health care team will provide information and/or care; however, I maintain the right to make all decisions regarding my care.

I understand that CHC may obtain medications for my treatment through Patient Assistance Programcs (PAP) sponsored by major pharmaceutical companies. if i meet eligibility requirements for PAP, I authorize the CHC Medical Director or designee to sign my name on the medication order form. My name will only be signed on medication orders specifically for me as prescribed by my health care provider. I understand that CHC may obtain medical records from other local hospitals/physicians to gain more medical history for my chart.

I consent to being treated at the CHC and consent to CHC obtaining previous medical history, including medications.

This consent is to remain in effect until it is revoked by me in writing.
Print Name*
Signature*

Clear
Date*

MonthDayYear
Date
Authorization for Verbal Communication & Medication Pick-up

I authorize CHC to verbally communicate my medical information with the following individuals. The individuals listed below are also given permission to pick up my medication from the CHC if I am unable to pick them up in person. If you do not wish to authorize another person for verbal communication and medication pick-up, please type N/A in the required fields.
Name*
Relationship to Patient*
Name
Relationship to Patient*
Please review the attached Patient Statement of Understanding, HIPAA Notice of Privacy Practices, and Free Clinical Federal Tort Claims Act (FTCA)
Acknowledgement and Receipt
By signing below, I acknowledge the following:

- I declare that I have completed this application to the best of my ability and that all information provided is true and accurate.

- I agree to provide the following documentation: photo ID, proof of household income, and a copy of my most recent tax return. (Proof of income is REQUIRED to determine eligibility for services and medications.)

- I agree to update CHC with any changes to my income and/or status of medical insurance.

- I have received a copy of the following documentation (These are provided on our website and can be downloaded above):

- Patient Statement of Understanding

-HIPAA Notice of Privacy Practices

-Free Clinic Federal Tort Claims Act (FTCA)
Print Name*
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

JEAN B PURVIS COMMUNITY HEALTH CENTER OF BUTLER COUNTY

Emergency Contact

EMPLOYMENT INFORMATION

Income Information

Members of the Household

DECLARATION OF NO INCOME

HISTORY AND PHYSICAL

LIST ALL CURRENT MEDICATIONS:

Immunizations

Social History

Medical History (Current and Past Conditions)

Most Recent

Family History

Consent to Treatment

Authorization for Verbal Communication & Medication Pick-up

Acknowledgement and Receipt