Hope Clinic Eligibility Verification Form

Eligibility Verification Form

Application Date: *

Patient name: *

First Middle Initial Last Name

Patient Date of Birth: *

What is your annual or monthly household income? To see if you quality, go to this link https://home.mycoverageplan.com/fpl.html *

Is the above figure a monthly or annual income? *

Monthly

Annual

Upload Proof of Income (Tax Form or last two paychecks)

Maximum upload size: 134.22MB

Verify and Attest to your Household Size: *

Verify and Attest to your Annual Household Income: *

I understand and attest to the information below by my answers to those that apply: My income is less than or equal to the 300% Federal Poverty Guideline as indicated by the Federal Poverty Level Table in the link provided above. *

Patient name (if minor, patient’s parent guardian name) *

Patient signature (if minor, patient’s parent guardian signature) *

Clear

Date *

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