IBA SUCCESS MAGAZINE Issue 3 Vol 3 | Page 22

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