ONLINE ENGLISH Enrollment Form: Created 6/4/24

Verify You Live in Virginia.
Which best describes you living situation:*

I currently rent or own a house/apartment/condo/trailer in Virginia.Friends/family are providing me with a place to stay in VirginiaI am living in a shelter in VirginiaI am homeless in Virginia.
Your Address and Residency Verification

Please provide information and proof of your Virginia residency
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Upload proof of residency *

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Please confirm the statement below:*

I declare that all information provided is true and accurate. I understand that it is my responsibility to inform Sinclair Health Clinic of any address changes and proof of address when I can in the future.

Information about you.

Please provide more information about your insurance.
Please tell us about what insurance you have:*

I do not have insuranceMolina HealthcareUnitedHealthcare Community PlanAnthem HealthKeepersPlan FirstAetna Better Health of VirginiaSentara Community Plan
Upload a picture of the FRONT of your Insurance Card*

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Upload a picture of the BACK of your Insurance Card*

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Determining the Number in Your Household

We define your household as YOU, your spouse, and any dependents (people you claim in your taxes).
Move the sliders in each category to match the number in your household . Leave at zero if there is no one in your household in a category
How many in your household, including yourself, are receiving income of any type. If no one, including yourself, is receiving income please enter '0'.*
You will be required to submit proof of income for the number of household members entered here.

	Monthly Gross Income
January
February
March
April
May
June
July
August
September
October
November
December

Household Income: Your SPOUSE/Legal Partner

You are seeing this section because you indicated that you are married (you are not required to submit income for a spouse from whom you are legally separated) You must provide proof of income for your spouse/legal partner in your household.
Spouse/Legal partner name:*

First NameMiddle NameLast NameSuffix
SPOUSE INCOME. Is your SPOUSE/ Legal Partner receiving income currently? Please select all that apply:*

Yes, paid weeklyYes, paid every two weeksYes, paid monthlyYes, self employed (do not have taxes taken out of my pay)Yes, but I don't have pay stubs and need my employer to verify my incomeYes, receiving unemploymentYes, receiving benefit/award/legal settlement income (Social Security payments, such as Supplemental Security Income, Social Security Disability Income, Retirement, Survivor’s Benefits, annuities, insurance policies, pensions, or death benefit or periodic allowances such as alimony, or child support)No, not making any income
Upload your weekly pay stubs for the past 30 days

Please upload images or scans of their pay stubs. If paychecks are direct deposited into your account, upload the electronic pay stubs. NOTE: Back statements are not considered acceptable proof of income.
Paystub 1 of 4*

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paystub 2 of 4*

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paystub 3 of 4*

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Paystub 4 of 4*

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Upload your bi-weekly pay stubs for the past 30 days

Please upload images or scans of their pay stubs. If paychecks are direct deposited into your account, upload the electronic pay stubs. NOTE: Back statements are not considered acceptable proof of income.
Paystub 1 of 2*

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paystub 2 of 2*

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Upload last month's pay stub

Please upload images or scans of their pay stubs. If paychecks are direct deposited into your account, upload the electronic pay stubs. NOTE: Back statements are not considered acceptable proof of income.
Monthly pay stub*

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Self Employment Income

Need Employer to Verify Income

The employer need to fill out the Employee Payroll Verification form. Continue with the application and we will send you the form after this application is submitted.
I need to be sent the Employer Verification Form. I will also upload two months of statements from my bank or the financial institution I use (Venmo, Cash App, Chime, or others). I will click NEXT to continue with the application.
Receiving Unemployment

Please upload the most current official unemployment benefit letter that shows the amount they are receiving.
Unemployment Benefit Letter image or scan*

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Receiving Other Benefits

You are seeing this section because you indicated your SPOUSE/Legal partner is receiving income from other state, federal or court mandated sources (Social Security payments, such as Supplemental Security Income, Social Security Disability Income, Retirement, Survivor’s Benefits, annuities, insurance policies, pensions, or death benefit or periodic allowances such as alimony, or child support). Please upload the official letters from each source showing the amount of benefit income being received.
Other Benefit images or scans. Upload all applicable benefit award letters.*

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No Income Certification

You are seeing this section because you indicated your SPOUSE/Legal Partner is currently not making any income of any type.
I, First Name* Last Name* (SPOUSE/Legal Partner), certify that I do not receive income from any of the following sources:
- Wages from employment (including commissions, tips, bonuses, etc.);
- Rental income from real or personal property;
- Interest or dividends from assets;
- Social Security payments, such as Supplemental Security Income, Social Security Disability Income, Retirement, Survivor’s Benefits, annuities, insurance policies, pensions, or death benefits;
- Unemployment
- Periodic allowances such as alimony, child support.
You are required to provide two months of statements from your bank or the financial institution you use (Bank, Venmo, Cash App, Chime, or others).

Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the best of my knowledge.

Signature* SPOUSE/Legal Partner

Date*
Two months of statements from your spouse's bank or the financial institution they use (Venmo, Cash App, Chime, or others)*

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	Monthly Gross Income
January
February
March
April
May
June
July
August
September
October
November
December

Other Members of Your Household Making Income

Please provide proof of income for ALL adult members of your household receiving actual income. DO NOT LIST dependent children under the age of 18.
I need to provide/upload proof of income income for:*

A dependent child (18 or older) or a dependent adult (not my spouse) in my household receiving incomeThere is no one else in my household making income.

	Monthly Gross Income
January
February
March
April
May
June
July
August
September
October
November
December

Your Household Income: Dependent Income (2)

Please provide the information below to help us determine your household income. You must provide proof of income for your spouse/legal partner in your household.
Name of the dependent (2) receiving income*

First NameLast Name
Dependent's relationship to you*
DEPENDENT INCOME. Is the dependant receiving income currently? Please select all that apply:

Yes, paid weeklyYes, paid every two weeksYes, paid monthlyYes, self employed (do not have taxes taken out of my pay)Yes, but I don't have pay stubs and need my employer to verify my incomeYes, receiving unemploymentYes, receiving benefit/award/legal settlement income (Social Security payments, such as Supplemental Security Income, Social Security Disability Income, Retirement, Survivor’s Benefits, annuities, insurance policies, pensions, or death benefit or periodic allowances such as alimony, or child support)
Upload weekly pay stubs for the past 30 days

Please upload images or scans of their pay stubs. If paychecks are direct deposited into your account, upload the electronic pay stubs. NOTE: Back statements are not considered acceptable proof of income.
Paystub 1 of 4*

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Not including this will result in an incomplete application. Cancelof
paystub 2 of 4*

Browse Files
Not including this will result in an incomplete application. Cancelof
paystub 3 of 4*

Browse Files
Not including this will result in an incomplete application. Cancelof
Paystub 4 of 4*

Browse Files
Not including this will result in an incomplete application. Cancelof
Upload bi-weekly pay stubs for the past 30 days

Please upload images or scans of their pay stubs. If paychecks are direct deposited into your account, upload the electronic pay stubs. NOTE: Back statements are not considered acceptable proof of income.
Paystub 1 of 2*

Browse Files
Not including this will result in an incomplete application. Cancelof
paystub 2 of 2*

Browse Files
Not including this will result in an incomplete application. Cancelof
Upload last month's pay stub

Please upload images or scans of their pay stubs. If paychecks are direct deposited into your account, upload the electronic pay stubs. NOTE: Back statements are not considered acceptable proof of income.
Monthly pay stub*

Browse Files
Not including this will result in an incomplete application. Cancelof
Self Employment Income

I   First Name   Last Name (dependant), do hereby certify that all the above income information for the past 3 months is true and correct.

Signature   Dependant
Date
Need Employer to Verify Income

The employer need to fill out the Employee Payroll Verification form. Continue with the application and we will send you the form after this application is submitted.
I need to be sent the Employer Verification Form. I will also upload two months of statements from my bank or the financial institution I use (Venmo, Cash App, Chime, or others). I will click NEXT to continue with the application.
Receiving Unemployment

Please upload the most current official unemployment benefit letter that shows the amount they are receiving.
Unemployment Benefit Letter image or scan*

Browse Files
Not including this will result in an incomplete application. Cancelof
Receiving Other Benefits

You are seeing this section because you indicated the Dependent is receiving income from other state, federal or court mandated sources (Social Security payments, such as Supplemental Security Income, Social Security Disability Income, Retirement, Survivor’s Benefits, annuities, insurance policies, pensions, or death benefit or periodic allowances such as alimony, or child support). Please upload the official letters from each source showing the amount of benefit income being received.
Other Benefit images or scans. Upload all applicable benefit award letters.*

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Not including this will result in an incomplete application. Cancelof
PLEASE ANSWER BEFORE CLICKING NEXT:*

I have reported all household income and am ready to continue

	Monthly Gross Income
January
February
March
April
May
June
July
August
September
October
November
December

PHARMACY: Supplemental Documents and Terms and Conditions

The documents request below are NOT necessary to become a patient of the clinic, but it will help the pharmacy at Sinclair Health Clinic provide you with reduced cost medications. Please read, acknowledge, sign, and date the below terms and conditions.
If you choose to submit an image of your Social Security Card or ITIN card, please upload it here.

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If you choose to submit an image(s) of your most recent federal tax return, please upload it here.

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--OR-- choose from the following options:

I do not have the supplemental documents today, but I will submit them at a later date.I decline to submit the supplemental documents requested.
I do not have prescription drug coverage. I agree to allow Sinclair Health Clinic to complete any patient assistance enrollment process on my behalf, which may include disclosure of personal and medical information. I also authorize Sinclair Health Clinic to share medical and financial information with any and all pharmaceutical providers including RxPartnership/Direct Relief for eligibility and audit purposes.

By signing below, I certify that I have read and agree to the terms and conditions listed above.
Signature*
Date*

Patient Disclosure and Consent

Please read, sign, and submit your completed application.
Signature*
Date*

Sinclair Health Clinic Policies.

Please review and sign each policy.
By signing below, I certify I accept the terms and conditions as outlined in the above policies. Signature*
Date*

Enrollment Application

We're sorry, you cannot become a patient with Sinclair Health Clinic.

We're sorry, you cannot become a patient with Sinclair Health Clinic.

Your Identification and Contact Information

Verify You Live in Virginia.

Your Address and Residency Verification

Information About You.

Information about you.

Determining the Number in Your Household

Your Household Income: The APPLICANT (You)

Upload your weekly pay stubs for the past 30 days

Upload your bi-weekly pay stubs for the past 30 days

Upload last month's pay stub

Need Employer to Verify Income

Receiving Unemployment

Receiving Other Benefits

No Income Certification

Household Income: Your SPOUSE/Legal Partner

Upload your weekly pay stubs for the past 30 days

Upload your bi-weekly pay stubs for the past 30 days

Upload last month's pay stub

Self Employment Income

Need Employer to Verify Income

Receiving Unemployment

Receiving Other Benefits

No Income Certification

Other Members of Your Household Making Income

Your Household Income: Dependent Income (1)

Upload weekly pay stubs for the past 30 days

Upload bi-weekly pay stubs for the past 30 days

Upload last month's pay stub

Self Employment Income

Need Employer to Verify Income

Receiving Unemployment

Receiving Other Benefits

Your Household Income: Dependent Income (2)

Upload weekly pay stubs for the past 30 days

Upload bi-weekly pay stubs for the past 30 days

Upload last month's pay stub

Self Employment Income

Need Employer to Verify Income

Receiving Unemployment

Receiving Other Benefits

Your Emergency Contact Information

PHARMACY: Supplemental Documents and Terms and Conditions

Patient Disclosure and Consent

Sinclair Health Clinic Policies.

Please answer the following questions honestly so that we can provide you with additional resources.