From the Community.
For the Community.
836 Richard Drive, Eau Claire, WI 54701
Phone: 715.839.8477; FAX: 715-839-8521
e-mail: [email protected]
website: www.cvfreeclinic.org
Pat i ent Handbook
Welcome to the Chippewa
Valley Free Clinic.
C H I P P E WA VA L L E Y F R E E C L I N I C PAT I E N T H A N D B O O K S I G N AT U R E
Please read the Patient Handbook carefully. If you do not understand something in the handbook, please ask
a Clinic staff or volunteer to talk about it. It is your responsibility to be familiar with the Clinic policies and
procedures.
To indicate you have read and understand the information in the handbook or someone has read it with you,
please print your name, sign, and date in the space below. Your signature will be kept in your Clinic record.
Thank you for your cooperation.
All patients are treated with
compassion and a non-judgmental
attitude. As a Clinic, we are caring
and act in ways that respect the
dignity, uniqueness, and important
worth of every person.
Patient name (please print): _________________________________________________________________________
Patient signature: ___________________________________________________________Date:__________________
IMPORTANT INFORMATION:
To qualify for services at the Chippewa Valley Free Clinic, proof of your income is necessary. You cannot receive
services at the Clinic without this proof. On the following list, the Patient Advocate or other Clinic staff member
will check the items you must provide. If the Clinic does not receive this proof by the date indicated, your
services will be discontinued.
W H AT I S T H E P U R P O S E O F T H E
HANDBOOK?
This handbook will help you and your family
• Understand the services provided
by the Clinic.
______ 2014 Tax Return
• Participate more actively in the care
you receive.
Need by: ____________________
______ 2014 Proof of Non-Filing (from the IRS Office)
______ BadgerCare Denial
(letter you received in the mail)
• Learn about Clinic procedures
important to your care.
Need by: ____________________
______ Hardship Waiver if 100-200% of poverty level
• Assume individual responsibility
as a Clinic patient.
Need by: ____________________
______ Social Security Disability
(letter you received in the mail)
Need by: ____________________
Need by: ____________________
______ Other: ______________________________________
Need by: ____________________
To indicate you understand what proof of your income is required and its due date, please sign and date in the
space below. A copy of this form with your signature will be kept in your Clinic record.
Patient signature: _______________________________________________________ Date: _____________________
Name & position of CVFC staff member receiving this document (after patient signature):
Print name & position_____________________________________________________Date: ____________________
Please make a copy after patient signature & CVFC staff member name & position are completed.
Return the Handbook with this original to the patient and keep a signed copy for Clinic records.
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W H AT A B O U T M E D I C AT I O N S?
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All medications are FREE IF YOU MEET ELIGIBILITY
REQUIREMENTS to receive Clinic services.
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The Clinic can provide medications free of charge (if
you meet eligibility requirements) because they are
provided by some drug companies. This service is
called the Patient Assistance Program or PAP; it helps
the Clinic keep costs down. To obtain medications
from the drug companies using the PAP, the Clinic
must have proof of your income (i.e., tax return or
proof of non-filing). Without proof of your income, the
drug company will not provide the medications.
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Some medications are not available at the Clinic
(e.g., narcotics, birth control).
The Clinic
W H AT I S T H E C H I P P E WA VA L L E Y F R E E C L I N I C ?
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provides health services for people of the Chippewa Valley
who have no other health care coverage.
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serves all patients without regard to personal, social, political,
or family beliefs or characteristics. It does not discriminate
in any way.
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protects you and your family’s privacy while providing
services. The Clinic will not share any information
that identifies you as an individual.
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depends on volunteers and generous support from the
community. Most of the clinic services are not funded by
the federal or state government.
A M I E L I G I B L E TO R E C E I V E S E RV I C E S ?
Your household income must be at or below 200%
of federal poverty guidelines. These guidelines are
available at the Clinic.
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You cannot be covered by any other health
insurance.
You cannot have access to any other health care
coverage. You are not eligible to receive Clinic
services if you qualify for VA
benefits, Medicare A or B, Medicaid, or disability.
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To confirm your eligibility, you must provide proof
of income. This will be a tax return or proof of
non-filing.
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W H AT S E RV I C E S D O E S T H E C L I N I C P R OV I D E ?
Tuesday Medical Clinic
Vision Clinic
• All Clinic patients are welcome. This includes
walk-in and ongoing/continuing patients.
• Every Tuesday 4 – 8pm
• Walk-in registration: 4 – 6pm
• Patients with diabetes: By appointment only
• 4th Thursday 5pm – 7pm: By appointment only
• Vision Clinic schedule may be expanded
Dental Care
• The Dental Clinic will start late Fall, 2015
Thursday Medical Clinic
Medication Refill
• All Clinic patients are welcome. This includes
walk-in and ongoing/continuing patients.
• 1st and 3rd Thursday 9am – 2pm
• Walk-in registration: 9 – 10am
• Patients with diabetes: By appointment only
• Medications will be re-filled ONLY (a) during
the Tuesday Medical Clinic and (b) at all Thursday
clinics.
• You MUST call the Clinic the day before pick-up to
request your medication re-fill: 715-839-8477.
This will help staff prepare your re-fill.
Mental Health Clinic
• 2nd and 4th Thursday 5pm – 8pm:
By appointment only
H OW S H O U L D I P R E PA R E
FOR MY VISIT?
MAKE AN APPOINTMENT
for the clinic service you need.
Appointments are required for
ALL services except the walk-in
clinics that are held on (a) Tuesday
evening 4 – 8pm and (b) the 1st
and 3rd Thursday 9am – 2pm.
To make your appointment, call
715-839-8477.
REMEMBER: If you cannot keep
your appointment, you must
call at least 4 hours before your
appointment time to cancel or
reschedule it. You will be dismissed
from the Clinic if you have
more than two appointment noshows (that is, you missed your
appointment and you did not call at
least 4 hours beforehand).
BRING YOUR PROOF of income
(tax return or proof of non-filing).
Our Clinic provides services at no charge to eligible patients.
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The Clinic can stop services to patients who:
~ Falsely describe their need or their information.
~ Do not follow Clinic rules as they are defined in this
Patient Handbook, or are disrespectful, abusive, or
combative do not use services as they were intended.
~ Have more than two no-shows for scheduled
appointments.
BRING A LIST of your medications.
W H AT C A N I E X P E C T D U R I N G M Y V I S I T ?
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To determine your eligibility for Clinic services, your
household income will be reviewed by a Patient Advocate.
The Patient Advocate will discuss the proof of income
you have with you or the proof you will need to bring. Any
other questions you have can be talked about at this time.
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After meeting with the Patient Advocate, you will meet
with a registered nurse. The nurse will do an initial check
(e.g., reason for your visit, blood pressure, etc.)
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You will then meet with a doctor or a nurse practitioner
who will do a more complete check and make decisions
with you about your health problem.
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You may be referred to other medical specialties (e.g.,
Eau Claire City-County Health Department for family
planning and STD testing/treatment) or to resources
in the community (e.g., food pantries, housing options,
job opportunities). A case manager or nurse will discuss
these referrals with you.
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Spanish language interpreters are available.
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Because the Clinic makes every effort to provide thorough
and high quality care to all patients, your visit at the
Clinic will take about two hours for most services.
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You will be treated with respect. You are expected to
respect all Clinic staff and volunteers. Verbal abuse
or combative behavior will not be tolerated and will result
in immediate dismissal from the Clinic.
Our Clinic does NOT provide (a) physicals for Workman’s
Compensation, (b) Commercial Driver’s License evaluations, (c)
STD and HIV/AIDS testing, (d) specialty care (e.g., OB/GYN, cancer)
or (e) preventive procedures (e.g., mammogram, colonoscopy). The
Clinic does its best to find available resources and/or refer those
patients who need these services.
Our Clinic does NOT give any controlled substances.
No narcotics are kept on the Clinic property.
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