Project Access New Enrollment Application

Thank you for your interest in applying for Project Access. We are a healthcare assistance program for residents of Richmond (6 months) and Columbia (1 year) Counties who are between the ages of 19 and 64, have no insurance, experiencing a current medical condition and have a household income that is at or below 200% of the federal poverty level.

In order to apply for our program, you will need to fully complete the attached application and gather the requested documentation. Once you have completed this information, you may mail, fax or drop your application off to the Project Access office at 2612 Commons Blvd., Augusta, GA 30909.

After we have reviewed your application and determined that it is complete, we will schedule a screening interview where you will meet with our Case Manager, review the application, answer any additional questions and sign any paperwork.

Applications are considered incomplete until all appropriate documentation has been received. Incomplete applications will be held for a period of 30 days and then destroyed. DO NOT send original documents as they will not be returned. We will not be held responsible if you send in original documents and they are destroyed.

If you submit your application by mail or fax, we recommend that you follow-up by phone if you have not been contacted by us within 2 weeks of submission.

If you have any questions regarding the application process, please feel free to contact our office at 706-733-5177.

Thank you.

Project Access New Enrollment
First NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Date
Gender*
I have read the term and conditions. Signature

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Social Security Number*
Driver's License Number or ID Number*
Marital Status*
Race
Housing*
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
County Of Residence*
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Alternate Phone

Area CodePhone Number
Who this Phone Number Belongs to:
Occupation*
Employment Status*
Education/Grade Level Completed*
Birth State*
US Citizen*
Household Position (ex. head spouse, father, mother)*
Number for Household Members?*

Financial Information*

	Type	Amount	Pay Period	Source
1
2
3
4
5

Current Health Problem*
Signature*

Clear
Date*

MonthDayYear
Date

ATTENTION PROJECT ACCESS APPLICANTS:
Please read the following declaration of our ZERO TOLERANCE policy and initial each paragraph. If you have any questions regarding this policy, please ask. Failure to read or understand this policy does not exempt you from being bound by these requirements.
Please be advised that Project Access has a ZERO TOLERANCE policy against failure to provide complete and accurate information. Attempts to withhold information may result in DENIAL of your application. Initial Below*
This policy requires that you disclose any and all information regarding your household members including, but not limited to, name, date of birth, income, assistance payments, address, phone numbers, etc. We expect all information be reported to us with supporting documentation upon submission of your application. Initial Below*
This policy coincides with our Patient Responsibilities that you will sign at enrollment. The requirements of this Zero Tolerance policy do not end at that time. This policy remains in effect the full length of your involvement in our program. Any changes occurring after you have originally applied or at any time during your participation must adhere to these policies and be reported immediately. Initial Below*
I understand that by signing this statement I am certifying that the information on my application is complete and accurate. If Project Access deems that I failed to disclose any information pertaining to members of my household, my application may be DENIED and I may be unable to apply for services in the future.
Print name
Signature

Clear
Date

MonthDayYear
Date

DOCUMENTS FOR PROJECT ACCESS
REQUIRED-GEORGIA DRIVERS LICENSE or ID

NOTE: We will NOT accept ANY expired or out of state licenses or ID cards. If you are unable to afford the cost of a license, the state offers a free ID card through the county registrar’s office or the Department of Drivers Services.

REQUIRED – PROOF OF RESIDENCY (must provide 2 acceptable documents below) NOTE: One document must be dated at least 6 months to 1 year ago for Richmond County residents or 1 year to 18 months ago for Columbia County residents and one document must be dated within the last 30 days. Documents must be in the applicants name and have a street address – we will NOT accept a PO Box. 
- Copy of utility bills or utility company records 
- Copy of bank statements 
- Copy of mortgage bill or notarized statement from a mortgage company
- Envelope of postmarked mail with applicant’s name and address (window envelopes are not accepted) 
- Copy of Voter Registration Card 
- Copy of doctor or hospital bill 
Magazines or other mail received with name. address, and date

REQUIRED – WG-15 FROM DEPARTMENT OF LABOR Regardless of work history, you must provide a copy of a WG-15 for ALL household members over the age of 16 dated within the last 30 days.

REQUIRED IF APPLICABLE – CURRENT BANK STATEMENTS or PAYROLL DEBIT CARD TRANSACTIONS Regardless of the amount available or if it is savings or checking, you must provide a copy of your most recent bank statement for any and all accounts for all family members. If you are receiving income via direct deposit to a payroll debit card, you must provide the last 30 days transaction history.

REQUIRED IF APPLICABLE – INCOME/ASSISTANCE PAYMENTS FOR ALL FAMILY MEMBERS

EARNED INCOME
- Last 3 check stubs 
- IF check stubs are unavailable, employer’s notarized statement on company letterhead including
  - (1) Employer’s name, address and phone number
  - (2) How much money is earned each pay period: average hours and wage earned
SELF-EMPLOYMENT INCOME 
- Current year’s IRS tax return, including Profit/Loss form (valid for use thru June of the following year) OR 
- Notarized Self-Employment Verification Form*
SOCIAL SECURITY (SSA), SOCIAL SECURITY DISABILITY (RSDI) OR SUPPLEMENTAL SECURITY INCOME (SSI) 
- Current award notice, letter, or statement from the Social Security Administration (you can print out a copy of your awards letter @ www.socialsecutity.gov/myaccount)
EDUCATIONAL GRANTS or SCHOLARSHIPS (paid directly to student)
-  Statement, letter or records from School, Organization, club or agency providing benefit
UNEMPLOYMENT COMPENSATION INCOME
-  Current award notice or statement from the Georgia Department of Labor
GOVERNMENT BENEFITS 
- Current Food Stamp/GATEWAY Account Letter
- Current Benefit letter for TANF or Childcare Assistance – we will NOT accept handwritten statements from DFCS – if you do not have a current letter, you can print the benefit summary from the FS GATEWAY website: www.gateway.ga.gov. ** 
- Current Housing Assistance Statement, including Utility Assistance if applicable
CHILD SUPPORT 
- Child Support Recovery statement and distribution records or current court records (court order, court support agreement divorce or separation papers, etc.) You can print your CS payment records @ dcss.dhs.georgia.gov
OTHER CONTRIBUTIONS
- Completed Contributions Form*
REQUIRED IF APPLICABLE – NO INCOME – TRANSIENT OR HOMELESS TRANSIENT (residing with relative or friend) 
- Proof of any government assistance (see above) 
- Completed Transient Certification Form* 
- NOTE: if you are living with a friend or relative an you are included in their Food Stamp case or they are claiming you as a dependent on their tax return, you are not considered “transient” and must provide documentation for all household members
HOMELESS (affiliation with a shelter or mission) 
- Proof of any government assistance (see above) 
- Statement from shelter or mission where you receive services
  
  *These forms are available on the Project Access website at www.rcprojectaccess.org or from the Project Access office.
  
  **Please note, proof of income or assistance payments applies to ANY received by the applicant and ALL other household members. If you are unsure of what is required of you please contact the Project Access office for clarification. Not providing all documentation could result in denial or dismissal under the Zero Tolerance Policy.
Please upload the all necessary documentation.

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Project Access New Enrollment

ATTENTION PROJECT ACCESS APPLICANTS:

DOCUMENTS FOR PROJECT ACCESS