Phone: (802) 264-8124 Fax: (802) 860-4311 www.chcb.org patientsupport@chcb.org

Application for Sliding-Fee Discountand Homeless Healthcare Program

4. Total Family Income (Anyone on your income tax return) Income Calculation Total Household Members Wages/Salary $____________ per____________ = $____________ From Sections 1 & 2 _________________ Self-employment $____________ per____________ = $____________ Unearned $____________ per____________ = $____________ Total Annual Income $_________________ (Specify type) ____________________________________________

5. Insurance Do you or your spouse have dental insurance coverage? c Yes c No Company ______________________________ Doyouoryourspousehavehealthinsurancebenefits?c Yes c No Company ______________________________ If yes, is it a Vermont Health Connect Policy? c Yes c No c Insured - Insurance Provider: c Uninsured c Filled out State Insurance Application (Green Mountain Care) c Application pending/Called GMC with patient to check application status

3. Are you a College/University student? c Yes c No (If “Yes” you will need to supply a copy of your FAFSA to apply.) Can you be claimed as a dependent on someone else’s tax return? c Yes c No (Ifyes,additionalincomeverificationisrequired)

Are you homeless? c Yes c No c Transitional Housing If yes, please describe: _____________________________________________________________________________ Where are you staying?: ____________________________________________________________________________

How long will you be staying there?: ___________________________________________________________________

Areyouawareofhomelessservicesinourcommunity?YesNo

1. ApplicantName (Last) ___________________________________________ (First)____________________________ (MI) _________Street Address __________________________________________ City________________ State ______ Zip____________Home Phone _______________________________ Date of Birth_________________ SS#__________________________Single____________ Married____________ Divorced____________ Separated____________ Widowed____________

2. Household Members(Whowouldbelistedonyourtaxreturndocuments) Name Relationship Birth Date Social Security #1. _________________________________________________________________________________________________

2. _________________________________________________________________________________________________

3. _________________________________________________________________________________________________

4. _________________________________________________________________________________________________

5. _________________________________________________________________________________________________

Burmese

6. Signature

By signing below I give permission to the Community Health Centers of Burlington, Inc. (CHCB) to share this document and any attachments thereto with University of Vermont Medical Center (UVMMC) for the purposes of enrollment in its sliding fee schedule. I understand this sharing of information may decrease any out-of-pocket cost to me for services ordered at CHCB but performed at UVMMC (e.g. laboratory testing). I also understand that I may revoke this permission if CHCB has not yet acted in reliance on it by writing ‘do not share with UVMMC next to my signature and that signing this document is not a condition of receiving treatment at CHCB or UVMMC.

To the best of my knowledge, the above information is true and correct. I agree to inform the Center of any changes inmy employment, financial status or housing. If the above information proves to be incorrect, I understand that the discount provided to me will be terminated. (I also give permission for the Health Center staff to contact my employer or any other source to verify income.)

It is expected that all patients will be forthright and honest about their medical coverage and financial information. Intention-al omission or falsification of identity, financial, or demographic information is fraud and may result in dismissal from the practice for up to one year. In the event of falsification, the patient will be responsible for the full payment of services.

_________________________________________________________________________________________________________ Signature of Applicant Date

FOR CENTER USE ONLYAuth. Initials _______________ Slide Level _______________ Approval/Denial Date _______________ Renewal Date _______________

Do you have a medical and dental provider?c Yes Medical Provider Name: __________________________________________________________c Noc Yes Dental Provider Name: ___________________________________________________________________________c No Dental Provider

Are you interested receiving information about any of the following community services?c Medicalc Dentalc Counseling c Food Shelf c Housing

Would you like us to connect you with services today? c Yes c No

Revised 7.19.19 CRD

Pleasereturnthisformwithoneofthefollowingformsofincomeverificationtopatientsupport@chcb.org:

• 2 consecutive paystubs from the last 30 days• SocialSecurity,disabilityorpensionbenefits

statements• IRS Form W2 or 1099• FAFSA form• Mostrecentlyfiledtaxreturn(form1040)• Unemploymentbenefitsstatement

Burmese

ေလာေဈးႏင အးအမမကနးမာေရး အစအစဥ ေလာကထားျခငး ဖနး- (802) 264-8124 ဖကစ (802) 860-4311 www.chcb.org patientsupport@chcb.org

1. ေလာကထားျခငးအမည (ေနာကဆး) _____________________________________________ (ပထမ) ______________________________ (အလယ) _______အမလပစာ ___________________________________________________ ၿမ႕ ___________________ ျပညနယ ______ ေဒသကဒ _______အမဖနး __________________________________________ ေမြးေန႔ __________________________ SS# ____________________________လလြတ ____________ အမေထာငရ ___________ ကြာရငး ________________ သးသန႔ခြေန _______________ တစခလပ _______________

2. အမေထာငစဝငမား (ဇနးခငပြနး/မခကေလး/ေဆြမး/အျခား) အမည ေတာစပပ ေမြးေန႔ လမႈဖလေရး #

1. __________________________________________________________________________________________________2. __________________________________________________________________________________________________3. __________________________________________________________________________________________________4. __________________________________________________________________________________________________5. __________________________________________________________________________________________________

3. သငသည ေကာလပ/တကသလ ေကာငးသားျဖစပါသလား? ဟတပါသည မဟတပါ သငသည တစစတစဥး၏ အခြနျပနရေငြအေပၚတြင မခေနရသ ျဖစပါသလား? ဟတပါသည မဟတပါ (ေနာကထပ ဝငေငြ အတညျပမႈ လအပပါက) သငသည အမယာမ ျဖစပါသလား? ဟတပါသည မဟတပါ ရခဖးလင ေကးဇးျပၿပး ရငးျပပါ- ____________________________________________________________________________________ သငဘယမာ ေနသနညး? _________________________________________________________________________________________ ထေနရာတြင သငမညမၾကာ ေနမညနညး? _____________________________________________________________________________ သငလမႈဝနးကငရ အမယာမဝနေဆာငမႈမားအေၾကာငး သပါသလား? ဟတပါသည မဟတပါ

4. မသားစ စစေပါငးဝငေငြ(သင၏ ဝငေငြခြနျပနရမႈအတြငး မညသမဆ) ဝငေငြတြကခကျခငး အမေထာငစဝင စစေပါငး လပအားခ/လစာ $ ____________ ကာလ ____________ = $ ____________

အပငး 1 & 2 မ ______________________ ကယပငလပငနး $ ____________ ကာလ ____________ = $ ____________ ဝငေငြမရ $ ____________ ကာလ ____________ = $ ____________

တစႏစဝငေငြစစေပါငး $ ____________________ (အမးအစား ေဖာျပပါ) _________________________________________________

5. အာမခသင သ႔မဟတ သငအမေထာငဖကတြင သြားအာမခ ရပါသလား? ဟတပါသည မဟတပါ ကမၸဏ ____________________________ သင သ႔မဟတ သငအမေထာငဖကတြင ကနးမာေရးအာမခ ရပါသလား? ဟတပါသည မဟတပါ ကမၸဏ ____________________________ ရပါက Vermont Health Connect Polity ဟတပါသလား? ဟတပါသည မဟတပါ

အာမခထားပါသည - အာမခအမည- အာမခ မထားပါ ျဖညစြကထားေသာ ျပညနယ အာမခေလာကလႊာ (Green Mountain Care) ေလာကလႊာ မကေသး/ ေလာကထားမႈအေျခအေန သရရန လနာႏငအတ GMC က ေခၚဆပါ

READ ONLY

Burmese

အသစျပငဆင 3.4..19 CRD

သငတြင ကနးမာေရးႏင သြား အာမခ ရပါသလား? ရပါသည၊ ကနးမာေရး အာမခအမည- _________________________________________________________________ မဟတပါ ရပါသည၊ သြား အာမခအမည- _________________________________________________________________________________________ သြားအာမခ မရပါ

ေအာကပါ လမႈဝနေဆာငမႈမားထမ တစခခအေၾကာငးက သငစတဝငစားပါသလား? ကနးမာေရး သြား ေဆြးေႏြးတငပငျခငး အစားအေသာက အမရာ

ကၽြႏပတ႔က ဝနေဆာငမႈမားအေၾကာငး သငက ယေန႔ ဆကသြယေစလပါသလား? ဟတပါသည မဟတပါ

6. လကမတေအာကတြင လကမတထးျခငးျဖင ကၽြႏပသည ယခစာႏင တြဖကပါတ႔က University of Vermont Medical Center (UVMMC) ၏ ေလာေစးအစအစဥတြငပါဝငခြငရေစရန Community Health Centers of Burlington, Inc. (CHCB) အား ခြငျပခက ေပးအပပါသည။ ယခအခကအလကမားက မေဝျခငးသညUVMMC မ လပေဆာငၿပး CHCB တြင ရယေသာ ဝနေဆာငမႈမား (ဥပမာ - ဓာတခြခနးစမးသပျခငး) တ႔အတြက အတစကအသးစားရတ ေလာသြားမညကနားလညပါသည။ ထ႔အျပင CHCB က ေဆာငရြကျခငး မျပရေသးလငကၽြႏပသည ယခခြငျပခကက ‘ကၽြႏပလကမတ ထးၿပးေနာက UVMMC ႏင မေဝျခငးမျပပါႏင၊ ယခစာက လကမတထးျခငးသည CHCB သ႔မဟတ UVMMC တြင ကသမႈခယရနအတြက မဟတပါ ဟ စာေရးသားၿပး ရပသမးႏငပါသည။

ကၽြႏပသသမ အထကပါအခကအလကမားသည မနကနပါသည။ ကၽြႏပ၏ အလပ၊ ေငြေၾကးအေျခအေန သ႔မဟတ အမရာ မညသညေျပာငးလမႈမဆ ဌာနကအသေပးမညရန သေဘာတပါသည။ အထကပါအခကအလကမား မမနကနပါက ကၽြႏပကေပးေသာ ေလာေဈးရပဆငးမညက နားလညပါသည။(ကနးမာေရးဌာန ဝနထမးမားအား ကၽြႏပ အလပရင သ႔မဟတ မညသညအရငးျမစကမဆ ဝငေငြအတညျပရန ဆကသြယခြင ျပပါသည။)

လနာအားလးသည ကနးမာေရးအာမခႏင ေငြေၾကးအခကအလကမားက ရးသားမနကနစြာ ေဖာျပရန ေမာလငထားပါသည။ ကယေရးအခကအလက၊ ေငြေၾကးသ႔မဟတ ေနထငမႈဆငရာ အခကအလကမားက ရညရြယခကရရ ထနခနျခငး သ႔မဟတ မားယြငးေဖာျပျခငးသည မသမာမႈျဖစၿပး အစအစဥမ တစႏစအထထတပယခရႏငပါသည။ မားယြငးေဖာျပပါက လနာအေနျဖင ဝနေဆာငမႈအတြက အျပညအဝ ေပးေခရပါမည။

ေလာကထားသ လကမတ ေန႔စြ

ဌာနတြငးသးရန အတြကသာ ခြငျပသ အစ စာလး __________ ေလာေဈးအဆင ____________ အတညျပ/ ျငငးပယ ေန႔စြ ______________ အသစျပနလပသည ေန႔စြ _________

ယခေလာကလႊာႏငအတ ဝငေငြအတညျပရန ေအာကပါ ပစမားထမ တစခက အတတြၿပး patientsupport@chcb.org သ႔ ေပးပ႔ပါ-

လြနခေသာ ရက 30 အတြငး ဆကတက လပအားခ ေငြေပးျဖတပငး 2 ခ လမႈဖလေရး၊ မသနစြမး သ႔မဟတ ပငစငခစားခြင ေဖာျပခကမား IRS ေလာကလႊာ W2 သ႔မဟတ 1099 FAFSA ေလာကလႊာ ေနာကဆးေလာကခေသာ အခြနျပနရမႈ (ေလာကလႊာ 1040) အလပလကမ ခစားခြင ေဖာျပခက

READ ONLY

Burmese