Phone: (802) 264-8124 Fax: (802) 860-4311 www.chcb.org patientsupport@chcb.org

Application for Sliding-Fee Discountand Homeless Healthcare Program

4. Total Family Income (Anyone on your income tax return) Income Calculation Total Household Members Wages/Salary $____________ per____________ = $____________ From Sections 1 & 2 _________________ Self-employment $____________ per____________ = $____________ Unearned $____________ per____________ = $____________ Total Annual Income $_________________ (Specify type) ____________________________________________

5. Insurance Do you or your spouse have dental insurance coverage? c Yes c No Company ______________________________ Doyouoryourspousehavehealthinsurancebenefits?c Yes c No Company ______________________________ If yes, is it a Vermont Health Connect Policy? c Yes c No c Insured - Insurance Provider: c Uninsured c Filled out State Insurance Application (Green Mountain Care) c Application pending/Called GMC with patient to check application status

3. Are you a College/University student? c Yes c No (If “Yes” you will need to supply a copy of your FAFSA to apply.) Can you be claimed as a dependent on someone else’s tax return? c Yes c No (Ifyes,additionalincomeverificationisrequired)

Are you homeless? c Yes c No c Transitional Housing If yes, please describe: _____________________________________________________________________________ Where are you staying?: ____________________________________________________________________________

How long will you be staying there?: ___________________________________________________________________

Areyouawareofhomelessservicesinourcommunity?YesNo

1. ApplicantName (Last) ___________________________________________ (First)____________________________ (MI) _________Street Address __________________________________________ City________________ State ______ Zip____________Home Phone _______________________________ Date of Birth_________________ SS#__________________________Single____________ Married____________ Divorced____________ Separated____________ Widowed____________

2. Household Members(Whowouldbelistedonyourtaxreturndocuments) Name Relationship Birth Date Social Security #1. _________________________________________________________________________________________________

2. _________________________________________________________________________________________________

3. _________________________________________________________________________________________________

4. _________________________________________________________________________________________________

5. _________________________________________________________________________________________________

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6. Signature

By signing below I give permission to the Community Health Centers of Burlington, Inc. (CHCB) to share this document and any attachments thereto with University of Vermont Medical Center (UVMMC) for the purposes of enrollment in its sliding fee schedule. I understand this sharing of information may decrease any out-of-pocket cost to me for services ordered at CHCB but performed at UVMMC (e.g. laboratory testing). I also understand that I may revoke this permission if CHCB has not yet acted in reliance on it by writing ‘do not share with UVMMC next to my signature and that signing this document is not a condition of receiving treatment at CHCB or UVMMC.

To the best of my knowledge, the above information is true and correct. I agree to inform the Center of any changes inmy employment, financial status or housing. If the above information proves to be incorrect, I understand that the discount provided to me will be terminated. (I also give permission for the Health Center staff to contact my employer or any other source to verify income.)

It is expected that all patients will be forthright and honest about their medical coverage and financial information. Intention-al omission or falsification of identity, financial, or demographic information is fraud and may result in dismissal from the practice for up to one year. In the event of falsification, the patient will be responsible for the full payment of services.

_________________________________________________________________________________________________________ Signature of Applicant Date

FOR CENTER USE ONLYAuth. Initials _______________ Slide Level _______________ Approval/Denial Date _______________ Renewal Date _______________

Do you have a medical and dental provider?c Yes Medical Provider Name: __________________________________________________________c Noc Yes Dental Provider Name: ___________________________________________________________________________c No Dental Provider

Are you interested receiving information about any of the following community services?c Medicalc Dentalc Counseling c Food Shelf c Housing

Would you like us to connect you with services today? c Yes c No

Revised 7.19.19 CRD

Pleasereturnthisformwithoneofthefollowingformsofincomeverificationtopatientsupport@chcb.org:

• 2 consecutive paystubs from the last 30 days• SocialSecurity,disabilityorpensionbenefits

statements• IRS Form W2 or 1099• FAFSA form• Mostrecentlyfiledtaxreturn(form1040)• Unemploymentbenefitsstatement

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Codsiga Sicir-dhimista Lacag-bixinta Adeegga iyo Guri la’aanta Barnaamijka Daryeel Caafimaad

Telefoon: (802) 264-8124 Fakis: (802) 860-4311 www.chcb.org patientsupport@chcb.org

1. Codsade Magaca (Dambe) ____________________________________________ (Koowaad) ___________________________ (Dhexe) ________ Cinwaanka Jidka ____________________________________________ Magaalo ______________ Gobol ________ Zip-ka _________ Telefoonka Guriga _______________________________ Taariikhda Dhalashada ____________ Lambarka SS _____________________ Aan guursan _______ Guursaday ____________ Furay _________________ Kala maqan _____________ La furay _______________

2. Xubnaha Qoyska (Lamaan/Carruurta Ku tiirsan/Qaraabo/Kale)

Magaca Xiriirka Taariikhda Dhalasho Sooshiyaal Sekuyuuriti#

1. __________________________________________________________________________________________________

2. __________________________________________________________________________________________________

3. __________________________________________________________________________________________________

4. __________________________________________________________________________________________________

5. __________________________________________________________________________________________________

3. Ma tahay arday Kuliyad/Jaamacad? Haa Maya Ma lagugu sheegi karaa inaad tahay qof ku tiirsan cashuur celinta qof kale? Haa Maya (Haddii ay haa tahay, caddayn dakhli dheeraad ah ayaa loo baahan yahay)

Ma tahay guri la'aan? Haa Maya Haddii ay haa tahay, fadlan sharax: ______________________________________________________________________________

Xaggee baad joogtaa?: _______________________________________________________________________________________

Intee in le'eg ayaad joogi doontaa halkaa?: ________________________________________________________________________

Miyaad ka warqabtaa adeegyada hoy la’aanta ee bulshadeena? Haa Maya

4. Wadarta Dakhliga Qoyska (Qof kasta oo ku jira cashuur celintaada) Xisabinta Dakhliga

Wadarta Xubnaha Qoyska Mushaharka/Mushaharka $ ___________ midkiiba __________ = $ ____________ Laga soo bilaabo Qaybahan 1 & 2 ________ Iskaa-u-shaqaysi $ ___________ midkiiba _________ = $ ____________ Aan la kasban $ ___________ midkiiba __________ = $ ____________ Isugeynta Dakhli Sannadle ah $ __________ (Cadee nooca) ________________________________________________

5. Caymiska Adiga ama lamaankaagu ma leedihiin caymiska ilkaha? Haa Maya Shirkad ______________________________ Adiga ama lamaankaagu ma leedihiin caymis caafimaadka? Haa Maya Shirkad ______________________________

Haddii ay haa tahay, ma tahay Vermont Health Connect Policy?

Haa Maya

Caymiska - Bixiyaha caymiska: Caymis la'aan Buuxi Codsiga Caymiska Gobolka (Green Mountain Care) Sugudda/Wicitaanka Codsiga GMC ee bukaanka si loo hubiyo xaaladda codsiga

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Dib loo eegay 3.4..19 CRD

Miyaad haysataa adeeg-bixiye caafimaad ama ilkaha ah? Haa Magaca Adeeg-bixiyaha Caafimaad: ___________________________________________________________ Maya Haa Magaca Adeeg-bixiyaha Ilkaha: _________________________________________________________________________________ Maya Adeeg-bixiye ilkaha ah

Ma waxaad xiisaynaysaa helitaanka macluumaadka ku saabsan mid ka mid ah adeegyada soo socda ee bulshada? Caafimaad Ilkaha La-talin Khaanadda Cunto Guri

Ma jeclaan lahayd in aan kugu xirno adeegyo maanta? Haa Maya

6. Saxeex

Saxeexa hoose waxan ku siinayaa oggolaansho Xarumaha Caafimaadka Bulshada ee Burlington, Inc. (CHCB) in ay la wadaagaan dhukumentiyadan iyo lifaaqyo kasta oo ahlkan University of Vermont Medical Center (UVMMC) ujeedooyinka isqorista ee jadwalka lacag bixinta. Waxan fahamsanahay in la wadaagidda macluumaadku ay iga yarayn karto kharashka ka baxsan jeebayga ee adeegyada ay dalabtay CHCB laakiin lagu fuliyay UVMMC (tusaale. Baadhitaanka shaybaarka). Sidoo kale waxaan fahansanahay in aan ka noqdo karo ruqsaddan hadii CHCB aysan weli isku halaynayn oggolaanshan adigoo ku qoraya 'ha la wadaagin UVMMC xaga ku xigta saxeexayga iyo in saxeexa dhukumentigan aanu ahayn shuruuda helitaanka daweynta CHCB ama UVMMC.

Si aan ugu fiicnahay aqoonteyda, macluumaadka kor ku qoran waa run iyo sax. Anigu waxaan oggolahay inaan wargaliyo Xarunta wixii isbedel ah ee ku yimaad shaqadayda, xaalad dhaqaale ama guri. Haddii macluumaadka kor ku xusan la caddeeyo inuu khaldan yahay, waxaan fahamsanahay in sicir-dhimista la i siiyay la joojin doono. (Sidoo kale waxaan u fasaxayaa shaqaalaha Xarunta Caafimaadka inay la xiriiraan loo-shaqeeyahayga ama ilo kale oo kasta si ay u xaqiijiyaan dakhliga.)

Waxaa la filayaa in dhammaan bukaanada ay si cad oo daacad ah uga waramayaan caymiskooda iyo macluumaadka maaliyadeed. Faahfaahin la'aanta ama ka been abuurka macluumaadka aqoonsiga, dhaqaalaha, ama macluumaadka dadweynaha waa khiyaano waxaana laga yaabaa inay sababto in kaqaybqadashada laga eryo ilaa hal sano. Haddii uu dhaco been abuur, bukaanku wuxuu mas'uul ka noqon doonaa lacag-bixinta adeeg oo buuxda.

Saxeexa Codsadaha Taariikhda

ISTICMAALKA XARUNTA KALIYA

Calaamadi Oggolanshaha _________ Heerka socodsiinta _____ Taariikhda Ansixinta/Diidamda ________ Taariikhda Jadiidinta _______

Fadlan foomkan ku soo celi mid ka mid ah foomamka soo socda ee caddaynta dakhliga patientupport@chcb.orglease:

2 jeeg mushahar ee isku xiga laga soo bilaabo 30 maalmood ee ugu dambeeyay Bayaanada dheefaha Sooshiyaal Sekuyuuritiga, naafonimada ama codsi Foomka IRS W2 ama 1099 Foomka FAFSA Cashuur soo celinta ugu dambaysay ee la xereyay (foom 1040) Bayaanka dheefaha shaqo la’aanta

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