Patient Financial Data

Northern Neck - Middlesex Free Health Clinic Patient Financial Data

Today's Date

Patient Name

Chart # / ID

Birth Date

Are you covered by Medicaid?

No Yes

Are you enrolled in Plan First?

No Yes

Are you on Medicare

No Yes

Does patient have prescription coverage?

No Yes

Do you have any other health insurance?

No Yes

Are you on disability (SSI through Social Security)?

No Yes

Do you file taxes?

No Yes

IF YOU DO NOT HAVE MEDICAID, PLAN FIRST, MEDICARE, OR ANY OTHER HEALTH INSURANCE, PLEASE SUPPLY THE FOLLOWING MONTHLY INCOME INFORMATION.

GROSS Wages, Patient

GROSS Wages, Spouse

Child Support

Disability, Patient

Disability, Spouse

Pension, Patient

Pension, Spouse

SSA (Social Security) Patient

SSA (Social Security) Spouse

SSI, Patient

SSI, Spouse

Unemployment Compensation

TANF/Other

TOTAL INCOME

Food Stamps (not included in total)

This information will only be used to determine financial eligibility and/or provide medical or dental treatment at the Clinic.

By checking this box I give my consent for this information to be used for this purpose.

I attest that this information is true and accurate. I will notify NNMFHC immediately of changes to insurance or income.

Date Attested