Patient Eligibility Application

Thank you for your interest in becoming a patient at The Free Clinic of Powhatan. We are committed to providing quality, comprehensive health care to our low-income, underinsured residents with compassion, dignity and respect.

To access the Clinic's services, you must first register to become a patient. Please complete the Patient Eligibility Application below. Once completed, you will be redirected to complete the required consent & agreement documents.

Please indicate the type of services needed:

Please indicate what type of patient you are:

How did you hear about the Clinic?

Partner Clinic Name:

Full Legal Name

First NameMiddle NameLast Name

Date of Birth

Social Security Number [SSN]

If none, type "None".

HOME Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

CELL Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Physical Address

Street Address

Street Address Line 2

CityState

Zip Code

County of Residence

How long have you lived in our service area?

Current living situation:


Pre-Screening Information

Are you traveling in the U.S. on a temporary Visa?

Type of Visa:

Please upload your Visa:

Do you have transportation?

What type of transportation?

Are you a Veteran of the USA?

% VA Disability

Have you applied for Veteran benefits?

Were you approved for Veteran benefits?

Please note - the clinic will need to review your application for eligibility.
Veterans who are eligible for benefits are recommended to seek care at the closest VA medical facility - learn more at www.richmond.va.gov.

Do you have MEDICAL Insurance?

Please indicate the type:

Did you lose your health insurance in the past 12 months?

What kind of health insurance did you lose? (Check all that apply)

Medicaid ID #

Effective Date

Please upload a copy of your current Medicaid card, front and back:

Do you have DENTAL Insurance?

Do you have PRESCRIPTION DRUG Coverage?

Do you currently receive Social Security Disability?

Effective Date

When and where did you last receive healthcare services?

In the past 12 months, how many times did you go to the Emergency Room (ER)?

Is your healthcare need the result of an accident?

Was the accident work-related?


Demographic Information

Primary Language

Other

Do you need an interpreter?

Race

Are you Hispanic/Latino?

Marital Status

Highest level of education

Gender at birth

What gender do you identify as?

Preferred Pronouns

Do you smoke?

In the next 30 days, are you:


Household Information

Emergency Contact

First NameLast Name

Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Relationship to Patient

May we use your emergency contact as an alternate means to contact you?

Please list the names and relationships of those you are financially responsible for - i.e. everyone listed on your tax form.

Rows	Name of Family Member	Date of Birth	Relationship to Patient
Patient
Family Member 1
Family Member 2
Family Member 3
Family Member 4
Family Member 5

Did you file taxes in the last year?

If you claimed a person/persons who does NOT live in your household, please list those persons here:

Did someone else claim you on their tax return?

Please list the name and relationship of who claimed you in their taxes:

You may upload your tax documents here – or you will need to bring copies to your screening appointment. [Note: Taxes must be signed and dated by person(s) filing taxes]

Files may be loaded as pdf, doc, docx, html, zip, jpg, jpeg, png, and/or gif


Employment Information

What is your employment status?

Please list your current employer(s):

Rows	Employer's Name	Phone Number	Time Employed	Occupation
Employer 1
Employer 2
Employer 3
Employer 4

How long have you been unemployed?

If unemployed, how do you provide food, shelter and other living expenses for yourself/family?

What is your spouse's employment status?

Please list your spouse's current employer(s):

Rows	Employer's Name	Phone Number	Time Employed	Occupation
Employer 1
Employer 2
Employer 3
Employer 4

How long has your spouse been unemployed?

Income Information

For the following section, please list the types of income, before taxes, earned by ALL PERSONS in the family unit. Include the following types of income: wages/salary/self-employment, child support/alimony, interest/dividends, disability benefits, retirement benefits, Social Security Income, Unemployment benefits, and any other type of income.

DO NOT INCLUDE INCOME FROM LOANS.

Rows	Name of Person Receiving Income	Relationship to Patient	Source of Income	Frequency
1
2
3
4
5
6

Please check which type(s) of most recent proof of income you can provide.

No income since:

Date

Statement of Unemployment

This is to verify that I, {fullLegal}, am unemployed and have recieved no income from {noIncome} to present.

Signature

You may upload your proof of income documents here – or you will need to bring copies to your screening appointment.

Files may be loaded as pdf, doc, docx, html, zip, jpg, jpeg, png, and/or gif


Dental Patient - Intake
As a prospective patient to our Dental Services, please complete the following questions as part of our dental intake.

Are you having dental pain now?

Please explain:

When did you last see a dentist?

By Whom

Please list any medications you are currently taking:

NOTE: we must have a list prior to any appointments.

Please upload a copy of your ID card – state issued license or ID card, federal ID card, passport, consular ID, permanent resident ID, etc.

Files may be loaded as pdf, doc, docx, html, zip, jpg, jpeg, png, and/or gif

Important: Do not close this page after clicking Submit.