Sinclair Health Clinic: New Patient Application

Please correct the errors described below.

Thank you for your interest in Sinclair Health Clinic. We are aware that many people would love to be one of our patients, but our mission is to help those who need us most. To see if you qualify for our services, please fill out this secure, encrypted, HIPAA-Compliant form. We do not share applicant information.

This information is not required. We need your SSN or Tax ID to get you access to cheap medicines. This can save you hundreds of dollars.
If you are living in a shelter, you can put the shelter name here. If you are living on the street, put "N/A".
    Please upload a file

    Complete the below section ONLY if you are uninsured.

    Identification and Personal Documents

      Please upload a file
        Please upload a file

        Proof of Residency

        We need a document with your name, address, and a date on it. This can include: Virginia issued stated ID/Driver's License/permit with current address, apartment or house lease, a most recent utility bill, letter from a homeless shelter, credit card or bank statements, insurance statements, change of address letter from the post office, or letter from a local municipality.

        We CANNOT accept PO Boxes.

        Please provide one (1) FULL page.

          Please upload a file

          Questions about Your Employment and Income

          We have to ask about your income to see if you qualify. We only provide care to people who make 300% of the federal poverty level or below.

          Your Income Sources and Amounts Per Month

          How much money do you make from the following per MONTH?

          Please attach the Award Letter of your most recent Social Security Benefit statement below.
          Please attach child support, alimony and settlements income benefit letter below.
          Please attach any of the following benefit letters below: Dividends, interest, capital gains, rental income, other income including from friends/family.
            Please upload a file
              Please upload a file

              Household Members

              Please remember that a household is you, spouse, and other dependents (or whoever is on your most recent tax return).

              Household= You + spouse + tax dependents (e.g. your children who are under 21 that you take care of and any dependent relatives you claim on your taxes). Do NOT include roommates.

              Click here to add another household member that receives monthly income or is employed.

                Please upload a file

                By submitting this application, I have read and agree to the following:

                PATIENT AGREEMENT/DISCLOSURE: I attest that this information is true and accurate. I agree that Sinclair Health Clinic (SHC) will be my primary care physician. I understand that if I knowingly withhold information or provide false information, it may be grounds for permanent dismissal and I will be responsible for any bills incurred. I give SHC staff permission to discuss and verify any and all information. I give SHC permission to share this information with the Winchester Medical Center if I am referred there for services.

                I affirm that I do not have prescription drug coverage. I agree to allow SHC to complete any patient assistance enrollment process on my behalf, which may include disclosure of personal and medical information. I also authorize SHC to share medical and financial information with any and all pharmaceutical providers including RxPartnership/Direct Relief for eligibility and audit purposes.

                I will immediately notify the Clinic of any changes to my income, household size, or insurance status.

                Your information will be encrypted.