• ANNUAL REVIEW

  • 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.

     

    ANNUAL REVIEWS, PROOF OF INCOME, AND LAST YEAR'S TAX RETURN (WHEN APPLICABLE) ARE REQUIRED TO REMAIN ELIGIBLE FOR SERVICES 

    Once you have submitted your application and all necessary documentation, we will contact you to schedule your annual review visit with our practitioner.

    Please note that failure to complete the renewal process and provide the required documentation may lead to a suspension of services or dismissal from the practice due to non-compliance.

     

    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)

     

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  • Application Date*
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  • Services Interested In*
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  • Consent to Text*
  • Permission to Leave a Voicemail*
  • Do you have health insurance?*
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  • Do you have dental insurance?*
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  • Are you a Veteran?*

  • Emergency Contact

  • EMPLOYMENT INFORMATION

    If no employment information, please type N/A
  • Marital Status*
  • Gender Identity*
  • Pronouns*
  • US Citizen*
  • US Resident*
  • Education*
  • Medicaid Status*
  • Transportation*
  • Employment Status*

  • Income Information

  • PLEASE NOTE: All patients seeking treatment at the Community Health Center are REQUIRED to submit proof of income and a recent copy of their most recent taxes, when applicable, BEFORE services will be scheduled. This information is needed to determine eligibility for the Community Health Center and is needed for any Prescription Assistance Program (PAP) applications.

    Services will NOT be scheduled until the applicable documents are submitted.

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

    1. Uploaded with the application

    2. Email: info@butlerhealthclinic.org

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

    4. Fax: 724-841-0984

  • How will you be submitting your documents?*

  • 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. 

  • Did you file a tax return last year?*

  • If you did not file for last year's tax cycle, or need assistance obtaining your tax return, below are a few ways to obtain last year's tax return.

    IF YOU FILED LAST YEAR: We need a copy of your 1040 return; we do not accept W2 copies as your return. You have to have the 1040 documentation

    IF YOU DID NOT FILE TAXES: We need proof of non-filing of taxes. This can be obtained the same ways listed below. You must submit proof of non-filing to be eligible for services.

    Methods to obtain verification of non-filing of taxes:

    1. Online (Fastest Option): https://www.irs.gov/individuals/get-transcript

         a. Create an ID.me account with the IRS to view past returns.

         b. If you filed, there will be "Return Transcripts" listed, which can be downloaded for each year listed.

         c. If you did not file, there will not be any "Return Transcripts" listed. You can take a screenshot of your screen and submit it for proof. (See Image below)

     

    2. Call 800-908-9946 for the automated phone transcript service

         a. Allow 5-10 calendar days for delivery via mail

     

    3. Mail: Must complete Form 4506 (attached) and mail to the corresponding address based on the state you lived in for the last year. 

         a. May take up to 75 calendar days

    OR

         b. Go to https://sa.www4.irs.gov/oat/ to request your transcript by mail.

            1. Fill out your personal details, then select "Return Transcript" and select last year. This return will be mailed to the address on file. DO NOT use this option if you have moved from the address on file from last year.

     

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  • Example of Online IRS Transcripts

    If you did not file, you may take a screenshot, like below, to show there was not a "Return Transcript" for the previous tax year.
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  • Tax return attached?*
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  • 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.

  • 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.

  • Date*
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  • Declaration of No Income (cont.)

    Please explain how you/your family are supporting yourself at this time

  • HISTORY AND PHYSICAL

  • LIST ALL CURRENT MEDICATIONS:

    Prescriptions, vitamins, aspirin, supplements, herbal remedies, and over-the-counter medications. If none, write N/A)
  • Are you currently taking any blood thinners?*
  • Have you ever been told to take a "pre-med" of antibiotics before dental treatment?*
  • Do you have a latex allergy?*

  • Immunizations

    Please fill out this portion to the best of your knowledge. If you have not received one of the immunizations, please type N/A.

  • Medical History (Current and Past Conditions)

  • High Blood Pressure*
  • Diabetes*
  • Heart Disease*
  • Asthma*
  • Stroke*
  • Date of Last Stroke
     / /
  • Cancer*
  • Anemia*
  • Elevated Cholesterol*
  • Seizures*
  • Arthritis*
  • Thyroid Disease*
  • Allergies (Environmental)*
  • Pneumonia/Bronchitis*
  • Emphysema*
  • Stomach Ulcers/GERD*
  • Hepatitis/Liver Disease*
  • Gallstones/Gall Bladder Disease*
  • Kidney Disease/Kidney Stones*
  • Back Problems*
  • Bladder or Kidney Infection*
  • Prostate Disease*
  • Gonorrhea/Syphilis/Chlamydia*
  • Alcohol/Drug Abuse*
  • Mental Illness*
  • Blood Transfusion*
  • HIV/AIDS*
  • Tuberculosis*
  • Anxiety/Depression*
  • Other*

  • 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.

  • 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. 

  • Date*
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  • 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.

  • EFFECTIVE JANUARY 1, 2026

    Notice of Privacy Practices must be read and acknowledged by all patients. This notice describes how medical and dental information about you may be used and disclosed and how you can get access to this information.

  • 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 and reviewed copies of the following documentation (These are provided on our website and can be downloaded above):

               - Patient Statement of Understanding

               -2026 HIPAA Notice of Privacy Practices

               -Free Clinic Federal Tort Claims Act (FTCA)

  • Date*
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