FHCCGLA Form -

Eligibility Screening Status Form

Patient’s Name: [esiggravity formid=”10″ field_id=”1″ display=”value” ]

D.O.B: [esiggravity formid=”10″ field_id=”2″ display=”value” ]

First Visit or Renewal: [esiggravity formid=”10″ field_id=”5″ display=”value” ]

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.

– Income Verification – (examples: Pay stubs, Income Tax Form, Disability Benefits, Workers Comp. Income, Self-employment letter).

[esiggravity formid=”10″ field_id=”7″ display=”value” ]
[esiggravity formid=”10″ field_id=”9″ display=”value” ]

– Address Verification – (examples: Any type of letter or bill received by mail to the patient’s address . Must indicate the patients name or guardian’s name).

[esiggravity formid=”10″ field_id=”10″ display=”value” ]

– Photo Identification – (examples: California Driver’s License, California l.D., Alien Registration Card, Student l.D., Credit Card with photo l.D.).

[esiggravity formid=”10″ field_id=”11″ display=”value” ]

If the patient does not provide all of the above eligibility documents at the time of Eligibility Screening, the patient MUST bring in the missing documents during their next scheduled clinic visit.

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Eligibility Status

▢ Patient was referred to apply for Medi-Cal or Emergency Medi-Cal

Date Referred: / /

▢ Patient is NOT eligible for any other program. Patient qualifies for F.F.S. ONLY at this time.
Reason:

Expiration Date: / /

(DO NOT sign or date unless Eligibility Screening is determined)

Eligibility Screening Completed By: ____________________________________ (Staff verification & Signature)

Date: / /

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FHCCGLA https://fhccgla.com

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April 28, 2020 2:32 pm PDT

Eligibility Screening Status Form Uploaded by Admin Name - fdiaz510@gmail.com IP 103.251.19.219