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Charlotte Community Health Clinic, Inc. (Charlotte Community Health Clinic)

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Revised 08.30.18
Charlotte Community Health Clinic, Inc.
ESTABLISHED PATIENT SLIDING FEE DISCOUNT PROGRAM APPLICATION
Charlotte Community Health Clinic is committed to providing quality health care to all members of the
community regardless of their ability to pay.
All patients of Charlotte Community Health Clinic with household income at or below 200% of the Federal
Poverty level and that provide required documentation will be eligible for medical, dental, and prescription
discounts.
Two pieces of information are required in order to qualify: the amount of money earned in the household and
the number of people who live in the household. To be eligible for the Sliding Fee Scale, you must provide
accurate and acceptable proof of income as well as list all persons within the household.
PLEASE RETURN THE ATTACHED APPLICATION AND PROOF OF INCOME (see below list) TO CCHC PRIOR TO YOUR
NEXT APPOINTMENT OR YOU WILL BE RESPONSIBLE FOR 100% OF ALL CHARGES AT THAT APPOINTMENT.
PLEASE PROVIDE COPIES – WILL NOT BE RETURNED
(Documents will be shredded for privacy after use)
Acceptable Proof of Income – Provide for each adult listed on application
• Most recent Federal Income Tax Return
• W-2 forms
• 30 days most recent pay stubs (more is better)
• Employer’s Letter on letterhead (must include contact name and phone number)
• Agency letter: A letter from the Social Security Administration, Veterans Administration or Social
Service Agency indicating income level.
• Unemployment Verification: Paperwork from the Employment Securities Commission (ESC)
proving unemployment status and the amount of unemployment compensation being
received.
• Alimony or Child Support Agreement
• Bank statement (only if it shows a direct deposit)
• Official Paperwork: Paperwork documenting retirement, disability, SSI benefits.
• If homeless: Letter from shelter where you are getting services
• If homeless/doubling up: Doubling up verification form
• If completely supported by a friend/relative, signed letter of support from that person
Complete and sign the attached application and return to CCHC, along with proof of income prior to
your next appointment:
Via email to financial.docs@cchc-clt.org
In person to Charlotte Community Health Clinic, 8401 Medical Plaza Dr, Suite 300, Charlotte, NC 28262
In person to Charlotte Community Health Clinic, 5301 Wilkinson Blvd, Charlotte, NC 28208
Revised 08.30.18
Charlotte Community Health Clinic, Inc.
ESTABLISHED PATIENT SLIDING FEE DISCOUNT PROGRAM APPLICATION
Name: DOB: _ _ MRN: __________Date Received: ______________
(Office Use Only) (Office Use Only)
The data gathered on this form will only be used to get information about you and your family so that we can
better meet your medical, behavioral health and/or dental needs. This form will not be used to withhold or
deny services to you.
1. Is any other family member applying for a discount with this application? Yes No
If yes, please indicate in final column below
2. Are you covered under Medicaid, Medicare or any other insurance? Yes No
3. If you have private insurance, what is your annual deductible, per family member? $__________
4. Are you unemployed? Yes No
5. Are you too sick to work or are you disabled? Yes No
TO BE COMPLETED BY PATIENT/GUARDIAN: Please include yourself, your spouse /partner, children and everyone else living in the home
*See attached list for acceptable forms for proof of income and household members
I have attached proof of income for the amounts listed above Yes No
***Documentation must be provided by patient or guardian to determine eligibility for Sliding Fee Scale***
I understand that the information I provide on this form is subject to verification by Charlotte Community Health
Clinic. I certify that the above information is true and correct to the best of my knowledge and that I
understand & agree that providing false information can result in me being denied ability to apply for the
program; furthermore I agree to adhere to all terms and conditions of the Sliding Fee Discount Program. I will
report any changes of the above information to CCHC. I also understand that I must supply proof of income
before my next visit, or I will have to pay the full price with no discount.
________________________________ _________________________________
Name*
Relation
in
Family
Date of
Birth
Income
Frequency
Proof of
Income*
Health
insurance
plans by
which
you are
covered
Applying
for
Assistance?
Example: John
Doe
Self
5/16/46
$346
weekly
Tax Form
Medicare
Yes
Revised 08.30.18
Patient Renewal Registration Form
MRN __________________________________ Date: ________________________
Patient Name: ___________________________________________________
(Last Name) (First Name) (Middle Initial)
Date of Birth: ___/___/___ Social Security/ W7: _____-_____-______
Mailing Address Information
Address __________________________________________________________________
City ______________________________ State ___________ Zip ________________________
Phone Number _____________________________________ (Please Select: Work/Cell/Home)
Alternate Phone # _________________________________ (Please Select: Work/Cell/Home)
Email: _______________________________________________________________________
Emergency Contact: _____________________________Phone #: _________________
Relationship: __________________
Sex: □Male □Female □Transgender (Male to female) □ Transgender (Female to Male)
Sexual Orientation: □ Straight (not lesbian or Gay) □Lesbian or Gay □ Bisexual □ something else □ don’t know
□ Choose not to disclose
Marital Status: □ Single □ Married □ Divorced □ Separated □ Widowed
Employed: □ Full time □ Part time □ Unemployed □ Student Full time □ Student Part Time
Race (Please select all that apply)
□ White/Caucasian □ Black/African American □ American Indian □ Asian
□ Native Hawaiian □ Other Pacific Islander □ Alaskan Native □ Other: ________________
Are you of Hispanic or Latino origin? □ Yes □ No
Country of Origen? _____________________________________________________________
Are you a Veteran of one of the U.S. Armed Forces? □ Yes □ No
Are you covered under BCBS, UHC, AETNA, Cigna, Medicaid, Medicare, Bright Health or any other Health
Insurance? □ Yes □ No
Revised 08.30.18
MRN: _____________________________
(HIPAA Release Form)
Patient Name: _____________________________________________ Date of Birth: _____/____/_____
Release of Information
[ ] I authorize the release of information including the diagnosis, records; examination rendered to me and claims
information. This information may be released to:
[ ] Spouse________________________________________
[ ] Child(ren) ______________________________________
[ ] Other__________________________________________
[ ] Information is not to be released to anyone.
This Release of Information will remain in effect until terminated by me in writing.
Messages
Please call
[ ] my home number _________________________
[ ] my work number _________________________
[ ] my cell Number ___________________________
If unable to reach me:
[ ] you may leave a detailed message
[ ] please leave a message asking me to return your call
[ ] __________________________________________
The best time to reach me is (day)___________________ between (time)_________
Signature of Patient (or Guardian): _____________________________________________ Date: ____/____/_____ Signature of
Witness: _____________________________________________________________ Date: ___/____/______
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Revised 08.30.18
MRN: _________________________
Notice of Privacy Practices
Receipt & Acknowledgement of Notice
Patients Name: ___________________________________________________________________
Date of Birth: ___________________________________________________________________
Social Security #: ___________________________________________________________________
I hereby acknowledge that I have received and given an opportunity to read a copy of the
Charlotte Community Health Clinic’s Notice of Privacy Practices. I understand that if I have any
questions regarding the Notice or my privacy rights, I can contact the Administrative Office at
704-384-1980.
___________________________________________________ __________________________
Patient Signature/Guardian/Personal Representative Date
__________________________________________________ _______________________
Signature of Staff Member Date
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signature
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Revised 08.30.18
Charlotte Community Health Clinic
Medical, Behavior Health and Dental Appointment Agreement
____ New Patients: Please arrive thirty (30) minutes early for patient registration.
____ Emergencies/Urgent:
Medical/BH: Patients are only allowed one (1) emergency/urgent appointment before the new patient
appointment.
Dental: Patients are only allowed one (1) emergency appointment as a new patient. The next appointment will
be for a comprehensive exam.
____ Sliding Fee Scale:
Dental: Proof of your card from CCHC is required at the first appointment. For patients that are not part of
CCHC, you are required proof of insurance. If you don’t have coverage you will be charge our full fee until
income information is provide to us or you can be seen under our walk in policy. All documents need to be
updated yearly.
Medical/BH: Proof of income or Insurance will be required at the first appointment. If you don’t have coverage
or proof of your income for the first visit you will be charge our full fee until income information is provide to
us. All documents need to be updated yearly.
____ Late Arrival:
Medical/BH/Dental: If you arrive more than fifteen (15) minutes late for your appointment, you may be ask to
reschedule or be worked in to a vacant appointment.
____ Cancellations:
Medical/BH/Dental: When cancelling an appointment, you must give at least twenty-four (24) hour’ notice.
When a patient misses an appointment, we miss the opportunity to care for the patient as well as another patient
who could have used that appointment slot.
Revised 08.30.18
____ No Show:
Medical/BH/Dental: (1) If an appointment is missed completely, (2) when the patient is more than 15 minutes
late by the clinic clock and has not called one full day (24 hrs.) ahead of the appointment to reschedule it’s a No
Show.* When a patient accumulates three (3) no show appointments consecutives in Medical or two (2) Broken
appointment on Dental, that person will not be allowed to schedule ANY further routine/ follow up
appointments for a period of six (6) month following the third consecutive no show in Medical or the second
broken appointment on Dental. Example:
____ Medical/ BH
I. First No Show: A note will be placed in the chart and the patient will verbally reminded of our
policy.
II. Second No Show: A note will be placed in the chart and the patient will verbally reminded again of
our policy.
III. Third No Show: Patient will not be allowed to make appointments in advance for a period of six (6)
months.
____ Dental
I. First Missed Appointment: A note will be placed in the chart and the patient will verbally
reminded of our office policy.
II. Second Missed Appointment: The patient will not be allowed to schedule another appointment for
six (6) months.
III. Third Missed Appointment: The patient will not be allowed to make advance appointments for a
period of one (1) year, except for emergencies.
• If a patient is schedule with another family member and the both fail to show for their
appointments, the family will no longer be able to schedule multiple appointment on the
same day.
I understand and agree to abide by Charlotte Community Health Clinic Appointment Agreement
Patient/Parent Signature: _____________________________ Date: __/__/__
Witness Signature: __________________________________ Date: __/__/__
MRN: ________________________
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Completed 13 May 2021

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