Employer Income Verification

Employer Income Verification
The patient named below has requested medical treatment from Volunteers in Medicine Clinic Hilton Head Island. To complete their registration, we kindly ask for verification of their employment and income for the work they perform. Please provide the requested information below.

This information will remain confidential and will not be shared with any government organization. It is protected under HIPAA guidelines. Thank you for your assistance.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Date of Birth

MonthDayYear
Date
Employer Information

Have the employer complete
Company Name
Company Phone Number
Please enter a valid phone number.
Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Income Verification
Hours per Week
Pay Per Hour
Additional Information
Employer Signature

Clear
Today's Date

MonthDayYear
Date
I understand that I must report any change in income status to Volunteers in Medicine Clinic Hilton Head Island.

I attest that the information provided is accurate, complete, and true to the best of my knowledge and belief. I acknowledge that any omission or inaccurate information could jeopardize the request for assistance.
Evaluator Signature

Clear
Today's Date

MonthDayYear
Date
Should be Empty:

Employer Information