eligibility

Eligibility Screening Form

We first need to determine if you are eligible for our services by asking these questions:

*indicates required fields

*Last Name:

*First Name:

*Address:

*City:

*Zip:

*Birthdate(mm/dd/yyyy):

*Home Phone:

*Cell Phone:

May we contact you at either phone number?:

yes
no

May we leave a message?:

yes
no

Have you been serviced by this clinic before?:

yes
no

How can we help you at this time?(problem):

specific symptoms:

Are you a Butler County resident?:

yes
no

What is your gross income(before taxes):

Do you have any health insurance?:

medical
dental
none
Medicare Part A
Medicare Part B
Medicaid/Med Access
Veteran's benefits
CHIP
Adult Basic

Have you applied for medical assistance?:

yes
no

no. of people you claimed for current tax return:

Employer:

The income guidelines listed below are used to determine Eligibility for services.

# in household

yearly income

             1

$21,660

             2

$29,140

             3

$36,620

             4

$44,100

             5

$51,580

             6

$59,060

             7

$66,540

             8

$74,020

add for each additional member

$7,480

Please click on the Submit button to submit the form details.

Documents you will be required to provide if scheduled for an eligibility appointment: Photo ID, proof of address, W2 form, most recent federal tax return, 30 days worth of pay stubs for household, and (if applicable) medical assistance denial letter.

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