Could ELIGIBILITY you be a patient CRITERIA at Grace Medical Home?
Could ELIGIBILITY you be a patient CRITERIA at Grace Medical Home?
Currently Between employed the ages of, OR birth have and been 65? employed within Earning the at last or less six months than 200, OR % of a full-time the Federal student, OR Poverty a single Line parent?( See of Federal a child Poverty under the Chart age) of 6?
PROVING Uninsured Currently YOUR employed and not ELIGIBILITY
enrolled, OR have in government been employed assisted healthcare within the last programs six months( such, OR as Medicaid a full-time, Share student of, WHAT DO YOU Cost OR a, Medicare single NEED parent TO or VA of BRING Benefits a child under)? TO YOUR the age of 6? ELIGIBILITY If you Uninsured APPOINTMENT answered and“ YES not enrolled” to? each in of government the above criteria assisted,
it is healthcare highly likely programs that you( could such as be Medicaid a patient, at Share of
Patient Grace Cost Eligibility Medical, Medicare Home or. VA Provide Benefits)? Proof Through Criteria the Following Documents If you answered“ YES” to each of the above criteria,
it is highly likely that you • Valid could Florida be a patient Driver at’ s Grace Medical Home. License or Photo ID
• Social Security Card
Proof of Identity
• Green Card
• Birth Certificate
• Voter’ s Registration Card
Living in Orange County for at least two months
Earning less than 200 % of the Federal Poverty Line
( See Federal Poverty Chart)
Grace Medical Home serves the working uninsured of Orange County, Florida who reside at or below 200 ELIGIBILITY % of the federal poverty CRITERIA line.
ARE Grace YOU Medical … Home serves the working uninsured of Orange County, Florida who reside at or below
Currently living in Orange County, Florida?
200 % of the federal poverty line. Between the ages of birth and 65?
ARE YOU … Earning at or less than 200 % of the Federal Poverty Currently Line living?( See in Orange Federal County Poverty, Florida Chart?)
Uninsured and not enrolled for government assisted health care programs( such as Medicaid, Medicare & VA benefits)
• Utility Bill
• Lease or Rental Contract
• Pay Stubs( Last 4 Weeks)
• Tax Return( 1040)
• Most Recent Tax Return or Letter of Support
• Letter from Employer Verifying Income
• College ID( if Applicable)
Patient may be required to sign a form verifying they do not have insurance.
All patients under the age of 18 must be accompanied by a parent or legal guardian. Legal guardians must supply proof of guardianship.
ARE YOU … Currently living in Orange County, Florida? Between the ages of birth and 65?
PROVING YOUR ELIGIBILITY
Earning at or less than 200 % of the Federal WHAT Poverty DO Line YOU?( See NEED Federal TO BRING Poverty TO Chart YOUR)
ELIGIBILITY APPOINTMENT? Currently employed, OR have been employed within Patient the last Eligibility six months, OR Provide a full-time Proof Through student, OR a single Criteria parent of a child the Following under the Documents age of 6?
Uninsured and not enrolled in government assisted
• Valid Florida Driver’ s healthcare programs( such as License Medicaid or Photo, Share ID of Cost, Medicare or VA Benefits • Social)? Security Card
If you Proof answered of Identity“ YES” to each • Green of the Card above criteria, it is highly likely that you could • Birth be a Certificate patient at
Grace Medical Home. • Voter’ s Registration Card
ARE YOU AT • OR Utility Bill
• Lease or Rental
BELOW 200 % THE Contract FEDERAL POVERTY LINE?
Living in Orange County for at least two months
• Pay Stubs( Last 4 Weeks)
|
Federal Poverty Chart
• Tax Return( 1040)
Earning less than
Uninsured
EXAMPLE
200
Number % of the Federal in
200
%• Most Poverty Recent Tax
200 % Poverty enrolled for
Poverty your Line Family
Annual
Return or Letter children
Monthly assisted an he of Support
Unit
Threshold
Threshold
( or programs $ 3,348
( See Federal
• Letter from Employer below
Medicaid 200
, %
Poverty Chart)
1
$ 23,760
Verifying Income
& VA bene
$ 1,980
|
2 |
• College ID
$ 32,040
( if Applicable)
|
$ 2,670 |
All patients und
COST legal guardian T.
|
3 |
$ 40,320 |
$ 3,360 |
Grace Med |
|
Uninsured
4 and not enrolled for government assisted health
5 care programs( such as
Medicaid,
6 Medicare
& VA benefits)
7
8
|
$ 48,600
Patient may be required
$ to 56,880 sign a form verifying they do not have
$ insurance 65,160.
$ 73,460
$ 81,780
|
$ 4,050
$ 4,740
$ 5,430
$ 6,122
$ 6,186
|
Volunteers donors ma services. P example, $
Tel: 40 visit include patient edu if extra test
|
9 |
$ 90,100 |
$ 7,508 |
outside of G |
10 |
$ 98,420 |
$ 8,202 |
experiencin with you. |
EXAMPLE: If you are a single parent caring for two |
|
children
Tel: 407.936.2785 and you earn Ext less. 2064 than | Fax $ 40,179: 407.936.2792 annually | www
|
( or $ 3,348 a month), then your family unit resides |
below 200 % the Federal Poverty Level. |
All patients under the age of 18 must be accompanied by a parent or legal guardian. Legal guardians must supply proof of guardianship.
COST TO PATIENT
Grace Medical Home is a non-profit medical home. Volunteers do most of the work here, and generous donors make it possible for us to provide these services. Patients pay a flat fee at each visit( for example, $ 10) and do not have to pay extra if the visit includes services like blood tests, X-rays, patient education, etc. There may be other costs if extra testing or specialty referrals are needed outside of Grace Medical Home. If you are experiencing financial hardship, we will work with you.
Tel: 407.936.2785 Ext. 2064 | Fax: 407.936.2792 | www. GraceMedicalHome. org
Cr
ARE YO
BELOW Proof of Id
FEDERA
Number in your Fami Living in O Unit
for at least 1
2 3 4
Earning les 200 % 5of th Poverty Lin
6( See Federa 7 Poverty Cha 8
9 10