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Today’s DATE: ______/2018___ (form updated 1/16/18)

ADDITIONAL INFORMATION VERIFICATION FORM

Community Clinical Services is a Federally Qualified Health Center (FQHC). We provide health regardless of ability to pay. Because we are an FQHC, we are required to gather this information annually.PLEASE NOTE: YOUR PERSONAL INFORMATION IS CONFIDENTIAL. WE WILL NOT DISCLOSETHIS INFORMATION TO ANYONE; THE INFORMATION IS USED IN AGGREGATE FOR FEDERAL REPORTING, AND TO HELP US UNDERSTAND OUR PATIENTS NEEDS.

PLEASE COMPLETE FOR THE ACTUAL PATIENT

Patient’sLast Name:______First Name:______M.I. _____

Date of Birth: ______Social Security Number: ______Gender:____

  1. What is your preferred language? __English __Somali __French __Arabic __Portuguese __Other
  1. Race: ___White ___Black/African American ___American Indian or Alaska Native ___Asian
___Native Hawaiian ___Other Pacific Islander ___More than one race
  1. Ethnicity: ___Not Hispanic/Latino __Hispanic/Latino
  1. Cultural Identity: __American __Somali __Somali/Bantu __ Djoubtian __Ethiopian __Burundian __Angolan __Congolese __Iraqi __Togolese __Kenyan __Other
  2. Are you a United States Veteran? __Yes __No
  1. Are you or a dependent an Agricultural Worker? __Yes __No
______
Household Size and Income Verification
Please circle the boxes for your household size and your household income. If you are under age 18, completing this form, you don’t need to complete this part.
My Household Size is… / 1 Person / 2 Persons / 3 Persons / 4 Persons / 5 Persons / 6 Persons / 7 Persons / 8+ Persons
My Household Income is
Below… / $24,280
($2,023 monthly) / $32,920
(2,743monthly) / $41,560
$3,463 monthly) / $50,200
$4,183 monthly) / $58,840
(4,903monthly) / $67,480
(5,623
monthly) / $76,120
($6,343monthly) / $84,760
$7,063
monthly)

____Check here if your household income is “above” the household size and you choose not to tell us the amount.

If your income is below 200% of poverty, you may qualify to receive a discount on your medical billing and may be eligible for free and/or low cost medications. Please ask us for a sliding fee scale application.

Thank you for completing this form!