3) Patient must have NO Private Medical, TennCare/Medicaid or

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1 Medical Eligibility Requirements 1) Patients MUST Reside In: Northeast Tennessee Southwest Virginia 2) Patient and/or someone in their household MUST be employed, unless they are retired or a student. 3) Patient must have NO Private Medical, TennCare/Medicaid or Medicare Insurance. Dental Eligibility Requirements 1) Patient MUST Reside In: Northeast Tennessee Southwest Virginia 2) Patient and/or someone in their household MUST be employed, unless they are retired, a student, a Veteran or disabled. 3) Patient must have NO Dental Insurance. Vision and Chiropractic Eligibility Requirements 1) Patients MUST Reside In: Abingdon, Virginia Bristol, Tennessee/Virginia Blountville, Tennessee Bluff City, Tennessee Elizabethton, Tennessee Piney Flats, Tennessee 2) Patient and/or someone in their household MUST be employed, unless they are retired or a student. 3) Patient must have NO Private Medical, TennCare/Medicaid or Medicare Insurance. Financial Guidelines Eligibility is based on total household income which may not exceed 200% of the Federal Poverty Guidelines. All applicants must bring Page 1 of 7 7/5/2016

2 their most recent paystubs, tax returns and income information for all members of their household. 245 Midway Medical Park Bristol, TN Phone Fax PLEASE READ CAREFULLY One Application per Person Thank you for expressing an interest in becoming a patient of Healing Hands Health Center. We are a faith based ministry providing healthcare to uninsured residents of NE Tennessee and SW Virginia. Please complete the attached application and medication record in black ink, and bring it with the documentation listed below to the clinic on one of the designated enrollment days. These times are first come first served. Enrollment days are: Monday: 2:00 4:00 PM Tuesday: 4:00 6:00 PM Wednesday: 10:00 AM Noon Thursday: 4:00 6:00 PM Please check our Facebook page for additional screening times that are periodically offered. If the required eligibility documentation is not provided, you will be asked to return on another enrollment day. For Dental Services Only 1. Proof of income for you and everyone in your household 2. A current piece of mail (preferably a utility bill) received at your address in your name (not junk mail) 3. Child Support (if you receive) documentation. 4. Your Social Security card. 5. Your Photo ID For Medical, Vision, Chiropractic, and Counseling Services: 1. Tax return AND most recent paystubs for each employed member of your household. Patient and/or someone in the household MUST be employed, unless he or she is retired or a student. 2. If you are self-employed you must provide documentation of all work done in the last 30 days (invoices, schedule book, etc.) or current 1040 tax return. Page 2 of 7 7/5/2016

3 3. Students not working need to provide their current class schedule. 4. Child Support (if you receive) documentation 5. Award letters for Social Security benefits, VA benefits and any other pensions (if applicable) 6. A current piece of mail (preferably a utility bill) received at your address in your name (not junk mail) 7. Social Security card 8. Your Photo ID Patient Fee schedule (Effective April 1, 2016) Medical Patient Visit $25 Dental Patient Visit $30 Dental Hygiene Visit $20 Vision Patient Visit $20 Eyeglasses $25 Chiropractic Patient Visit Counseling Patient Visit Physical Therapy Patient Visit Medication Admin Fee $15 $15 $15 $5 per medication ($35 cap per visit) Page 3 of 7 7/5/2016

4 Giving false information or withholding information will disqualify you for the services. Patient Application Please Print - Use Black Ink Have you ever been seen in one of Healing Hands Clinics? Yes No Date / / Last Name First name MI Social security # Date of birth Address City State Zip County Home phone Cell Work phone address Can we leave detailed messages: At Home At Work? Through the mail? Please list the people that we may discuss your health care with: Gender: Male Female Race: Caucasian African American Hispanic Other Marital Status: S M W D Sep. Number of people living in household Is patient eligible to file as female head of household on tax return? Yes No Emergency contact not living with you Relationship Emergency contact phone numbers Have you ever been convicted of or pleaded no contest to a felony? Yes No If yes, please provide a complete explanation Page 4 of 7 7/5/2016

5 Health insurance information: TennCare / Yes No Veteran s Benefits: Yes No Medicaid: Medicare Part A: Yes No Medicare Part B: Yes No Medical insurance: Yes No Dental insurance: Yes No Workman s Comp: Yes No Affordable Care Act: Yes No Have you applied for TennCare/Medicaid? Yes No Are you a patient at Twin City Medical Center? Yes No Are you currently seeing a private doctor? Yes No name How recently have you seen a private doctor? Have you been declared legally disabled? Yes No Yes No Employment information: Doctor s I am: Employed Employer Occupation Are you a Veteran? Unemployed Date unemployment started Student School Phone Retired From Disabled Other Adult Household member name(s) Birthdate Employed Employer Occupation Unemployed Date unemployment started Student School Phone Retired From Disabled Please list all other household members and their date of birth below: Name Relationship Date of Birth Page 5 of 7 7/5/2016

6 Patient Certification: Healing Hands Health Center is a private, non-profit clinic operated primarily by staff and volunteers and provides health care for the working uninsured residents of our community and their families. I understand that the volunteer providers at Healing Hands Health Center render these services voluntarily, without compensation or the expectation or promise of compensation. Should I need a referral to a specialist, I understand that I am responsible for any bills that may result from any referrals or visits to the Emergency Room. I authorize Healing Hands Health Center to release the necessary medical records needed for any referral. Also, I authorize representatives of Healing Hands Health Center to sign applications on my behalf for any medications that need to be ordered from the Patient Assistance Program. I have received a copy of the Healing Hands Health Center Patient Rights and Responsibilities. I understand that if I am a no show for an appointment, I will pay a $25 reinstatement fee before I can get another appointment in any Healing Hands clinics. I certify that the information I have provided is true and complete. I understand that if I give false information or withhold information I will no longer be eligible for services. This policy is strictly enforced. Rudeness and foul language to our volunteers, staff and other patients will not be tolerated and you will be dismissed from the clinic. Patient signature Date This project is funded under an agreement with the State of Tennessee and the Commonwealth of Virginia. Current Medication List Name: Date of Birth: Medication Name & Dose How often do you take it? How long have you been taking it? If you are out of it, how long have you been out? Example: Zocor 40 mg Once a day 6 months 1 month, 2 days, etc. Page 6 of 7 7/5/2016

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