VOLUNTEER HEALTH CARE PROVIDER PROGRAM - FINANCIAL ELIGIBILITY FORM
Luz Del Mundo – Light of the World Clinic, Inc.
806 E. Prospect Rd., Oakland Park, FL 33334
Phone: 954-563-9876 Fax: 954-563-3670
BOX 1 Do you have health or dental insurance for your medical condition? YES _______NO _________
Do you hav any of the following? (Check all that apply)
 Medicaid
 Medicare
 Medical disability
 Workmans comp
Today’s Date: ____________________________
Application for:
 Individual
 New Application
__________________
(FIRST NAME)
(LAST NAME)
Race:
White
Black
_______________
(ZIP CODE)
(CITY/STATE)
Date of Birth (DOB)_________________
Asian
Social Security # or TIN #:
American Indian Pacific Islander
 Renewal Application
________________
(MIDDLE INITIAL)
Address:
(STREET)
 Other clinic/facility _____________
Referred By: ____________________________________________
 Family of _____________
Name:
 Kidcare
__________
Ethnicity:  Hispanic
 Male  Female
 Other: ________________
(please circle one of the above)
Telephone #: (_____)___________________ (
)_____________________ Email: ______________________________
(Home)
(Cell)
Status: (please indicate your marital status)  Single  Married
 Separated
 Divorced
 Widowed
 Common law
Name and Telephone of an Emergency Contact: _________________________________(______)___________________
(Name)
BOX 2
Family Size:
Adults _____
FAMILY MEMBER
Under 18 _____
DOB
( Telephone )
18-21--Student _____
EMPLOYER
Unborn ______
GROSS MONTHLY
EARNED INCOME
TOTAL _______
GROSS MONTHLY
UNEARNED INCOME
$
$
SPOUSE
$
$
CHILD
$
$
CHILD
$
$
CHILD
$
$
$
$
TOTAL FAMILY
INCOME (Earned +
Unearned=)
TOTAL FAMILY INCOME
$___________________
SELF
_______________________
Address:________________
_______________________
Occupation:______________
INCOME TOTALS
USE CURRENT YEAR FEDERAL POVERTY GUIDELINES FOR INCOME DETERMINATION
BOX 3
I certify by my signature that, to the best of my knowledge, the above is a true and complete statement of my financial situation. I understand
that the information I have given is subject to verification by the Department of Health. I acknowledge I am responsible to inform the
Department of Health of any change in my financial or health insurance status prior to my next visit. I acknowledge receipt of the Department
of Health’s Notice of Privacy Practices.
X___________________________________________
_________________________________________________________
SIGNATURE OF PATIENT/PARENT OR GUARDIAN
DEPARTMENT OF HEALTH VOLUNTEER OR STAFF
DATE
6/23/10
(VALID FOR ONE YEAR) Expiration date: _______________________________________
Original – Bay CHD
Yellow copy - patient file
Applicant must provide COPIES of the following
documents with their application for consideration
and final approval.
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COPIES of 2 forms of photo identification for each person applying.
Proof of Residency Requirements:
 COPY of current lease agreement / contract along with a copy of the last rent payment
receipt. OR
 Copy of last paid mortgage statement.
 It you don’t have a rental agreement or own a home then you MUST submit a completed
“Rent Verification Form” or an ORIGINAL notarized letter that contains the following
details of your current living arrangement:
 Monthly rental amount
 Complete address with city and zip code
 Are utilities included?
 Length and terms of living arrangement (monthly, yearly)
Proof of income requirements:
 COPIES of the last 3 consecutive paystubs for ALL adults in the family.
 If your employer pays you in cash you MUST submit an ORIGINAL notarized letter
verifying employment.
 If you are self-employed, you MUST submit an ORIGINAL notarized letter stating your
occupation and monthly income.
 If you don’t work, you MUST still submit an ORIGINAL notarized letter stating that you
have no income and explain why.
COPY of your last FPL and phone bills.
COPY of your most recent tax return including W2/1099.
COPY of all car registrations for the household.
BOX 4 BUDGET COMPUTATION (To be completed by clinic staff if family income is above federal poverty level.)
Step 1.
Total “GROSS MONTHLY EARNED INCOME” (before deductions) for family unit (Wages, Salary, Tips). (1) $ ____
(Above)
Step 2.
Subtract $90 for EACH employed member of the family unit.
(2) $ _____
(Minus)
(3) $ _____
(Total)
(4) $ ____
(Minus)
Step 3.
Subtract childcare PAID each month (up to $175 per child age 2 and older;
up to $200 per child under age 2).
TOTAL NET EARNED INCOME
(5) $ _________(Total)
Total “GROSS MONTHLY UNEARNED INCOME“ for the family unit (VA, SSA, Unemployment
Compensation, Child Support) (DO NOT INCLUDE TANF OR SSI PAYMENTS).
(6) $ _____
(Above)
Step 5.
Subtract up to $50 per month of total child support received.
(7) $ _____
(Minus)
TOTAL NET UNEARNED INCOME
Add Total Net Earned Income and Total Net Unearned Income.
ADJUSTED TOTAL NET INCOME FOR FAMILY UNIT
(8) $ _____
(Total)
Step 6.
(9) $
(Total)
Step 4.
Original – Bay CHD
__
Yellow copy - patient file