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Eligibility Screening Status Form

  • Date Format: MM slash DD slash YYYY
  • All patients must be screened during their initial visit and annually thereafter for eligibility. A copy of the below-listed documents are required to be in the patients file.
  • (examples: Pay stubs, Income Tax Form, Disability Benefits, Workers Comp. Income, Self-employment letter)
  • (examples: Any type of letter or bill received by mail to the patient's address. Must indicate the patients name or guardian's name)
  • (examples: California Driver's License, California l.D., Alien Registration Card, Student l.D., Credit Card with photo l.D.)

 

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This resource is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $2,933,524 with 60% financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.

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