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 CHCBC 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.
- If you do not have any earned income you will need to complete a ‘Declaration of No Income’ form available at the clinic or by downloading the declaration of no income form.
Current Federal Income Tax Return (If you did not file a tax return for the previous year you will be required to sign a form to document this)
- Form 1040 ONLY (1-2 pages – must include your signature)
- If Self-employed, the Schedule C (Profit/Loss Statement) will be required
*We do not accept W2 Forms
**If you do not have a copy of your tax return – please call 1-800-908-9946 to request a tax transcript.
Medical Assistance Denial Letter
A CHCBC representative will advise if you need to present a MA denial letter once we review your application for services. If you already have a denial letter current within the past 6-months we will copy this. Please note: Other programs that we collaborate with may require you to present a letter of denial for Medical Assistance even if we determine you would not qualify. It is the patient’s responsibility to comply with each programs requirements.
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).