Sinclair Health Clinic: New Patient Application

Need Help?

If you cannot fill out this form, please call 540-536-1614.

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 is:

A new patient application

A renewal application

First Name

Middle Initial

Last Name

Social Security Number or Tax ID number

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.

Date of Birth

Gender

Female Male Non-Binary or third gender

Language

English Spanish Other

Which of the following best describes your living situation?

I rent an apartment or own a house I am between apartments and/or living with friends/family I am living in a shelter I am living on the street

Street Address

If you are living in a shelter, you can put the shelter name here. If you are living on the street, put "N/A".

City

Zip Code

This address is my:

Physical address only

Mailing address only

Both physical and mailing address

Primary Phone Number

Can we text you or leave messages at this number?

Yes, you can text me

Yes, you can leave voice messages

Other Phone Number

How did you hear about us?

Friend or Family Facebook Web Search Department of Social Services Other

If other, please write how you heard about us below:

Do you have health insurance?

No, I do not have insurance. I have not applied for Medicaid.

Please continue with the application.

Yes, I am on Medicaid with Virginia Premier or Optima

You are all done. Please submit the form now. Call us at 540-536-1680 to schedule an appointment.

Yes, I am on Medicaid. I do not know my MCO.

We'll give you a call. Please submit the form now.

I applied for Medicaid. I have not heard back.

I applied for Medicaid. I was denied.

Please upload your denial letter.

Yes, I have private health insurance.

Unfortunately, we only accept uninsured patients and those on Medicaid at this time.

Yes, I have Veterans Affair Benefits.

Unfortunately, we only accept uninsured patients and those on Medicaid at this time.

Yes, I have Medicare.

Unfortunately, we only accept uninsured patients and those on Medicaid at this time.

Upload your Medicaid card or denial letter here.

Add file

Please upload a file

Complete the below section ONLY if you are uninsured.

Identification and Personal Documents

Upload copy of identification Picture of Drivers License, passport, jail ID, or other photo ID.

Add file

Please upload a file

Social Security Card or Tax Identification Number (ITIN) This helps us get you the medications you need.

Add 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.

Upload Proof of Residency

Add file

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.

Which of these best describes you? Check all that apply

Employed full-time

We will need the last 30 days worth of paystubs or a letter from your employer.

Employed part-time

We will need the last 30 days worth of paystubs or a letter from your employer.

Employed, seasonal

We will need the last 30 days worth of paystubs or a letter from your employer.

Self-employed

We will need for you to complete our "Self-Employment" form attached on our website.

Unemployed

We will need for you to complete our "No Income Certification" and complete our "Verification of Support" that is attached on our website.

Unemployed and receiving benefits

This includes any benefits from Social Security.

Your Income Sources and Amounts Per Month

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

Wages from Job (before taxes, gross income)

Social Security Benefits (retirement, disability, supplemental security income, and/or survivor benefits)

Please attach the Award Letter of your most recent Social Security Benefit statement below.

Court Mandated Payments Received by Your Household (Income)

Please attach child support, alimony and settlements income benefit letter below.

Other Income Sources

Please attach any of the following benefit letters below: Dividends, interest, capital gains, rental income, other income including from friends/family.

File attachments- Pay Stubs Please attach a copy of all pay stubs you received last month. Your name must be on it. If you recently started, you can provide your offer letter or letter from your employer that states how much you earned last month (on company letterhead). If you get paid in cash, please fill out a Employee Payroll Verification form.

Add file

Please upload a file

Proof of other income: Award letters for unemployment benefits, Social Security, Disability, Retirement/Pension, Housing assistance

Add 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).

How many people are in your household (INCLUDE YOURSELF)?

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.

Are you the only person in your household making income

yes, I am the only one. no, others are making income. I have added them above. I am not making any income

Upload pay stubs and Proof of other income (Award letters of unemployment benefits, Social Security, Disability, and Retirement/Pension) from ALL employed household members.

Add file

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.

Sinclair Health Clinic: New Patient Application

Need Help?

Complete the below section ONLY if you are uninsured.

Identification and Personal Documents

Proof of Residency

Questions about Your Employment and Income

Your Income Sources and Amounts Per Month

Household Members

Need Help?

Dr. Terry Sinclair Health Clinic