Additional Documentation Required to Determine Eligibility for CHCBC Services:

The Community Health Clinic does not duplicate services already 
available in our community. The following documents are required to assist 
us in determining your eligibility for services.

Income for all members of your "household"
 - “household” is defined by the number of individuals you have claimed on your most recent tax return

 - See CHCBC Patient Registration Page #3 for more information on what type of income documentation is required.

- If you do not have any earned income you will need to complete the Verification of No Income Documentation form

Current Tax Return

 - Form 1040 ONLY (1-2 pages – must include your signature)

 - We do not accept W2 Forms

 - If Self-employed, remember to copy your Schedule C (Profit/Loss Statement)

  *If you do not have a copy of your tax return – please call 1-800-829-1040 to request a tax transcript.

Medical Assistance Denial Letter

 - Please provide a denial letter IF AVAILABLE WITHIN THE PAST 6-MONTHS.

 - If you have not applied you may be required to do so. The CHCBC will advise this after reviewing your eligibility for services.

Valid Photo ID

 - If your current address is different than the address listed on your Photo ID – proof of your current address will be required (bill, bank statement, etc).