Sinclair Health Clinic: New Patient Application

Please correct the errors described below.

Thank you for your interest in becoming a patient at Sinclair Health Clinic. Many people would love to be a patient here, but we can only help those who need us most. We need some information to see if you qualify. (Millionaires need not apply.) This is a secure, encrypted, HIPAA-Compliant form. Your information is heavily protected.

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 "NA".

    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. Only 1 page is needed.

          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.

          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.

          Household Members

          Click here to add another member of the household

          Your Income Sources and Amounts Per Month

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

          Please provide the most recent Social Security Benefit statement.
          Include child support, alimony and settlements here.
          Dividends, interest, capital gains, rental income, other income including from friends/family
            Please upload a file
              Please upload a file
                Please upload a file

                Monthly Income of Other Members of Your Household

                CLICK HERE to add another household member. We need this information for each member of your household even if the income is $0.

                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.

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