Questionnaire

PROOF OF IDENTIFICATION, RESIDENCY, AND INCOME

| Note: You are required to submit proofs of your Identification, Residency and Income along with this Eligibility Application. See the page Acceptable Proofs of Eligibility for instructions.

PATIENT AGREEMENTS

1. General Agreements:
   • I have attached the acceptable proofs of eligibility that are outlined in this application.
   • I certify with my signature below, that the above information is a full and complete disclosure of my income and address. I certify that the above information is true to the best of my knowledge and there is no attempt to commit fraud. I understand that appropriate action will be taken if the above information is found to be false.
   • I recognize that other people are donating their time and their money so that I may receive free health care. I am grateful for their help. I certify with my signature below, that the financial information I have provided with this application is correct. I give my permission for Hope Within to verify what I have stated with any of the sources mentioned above.
   • I recognize that Hope Within Community Health Center has limited liability malpractice coverage. The coverage at Hope Within is provided under the FTCA (Federal Tort Claims Act). This coverage allows the Department of Health and Human Services to be the primary provider of malpractice insurance in regard to any negative effects from volunteers. Hope Within’s providers are essentially viewed as employees of the public health service. The malpractice coverage also applies to any of Hope Within’s board members, staff, or volunteers that provide care at our office or other events sponsored by our health center.
   • I recognize that the Hope Within healthcare professionals strive to treat me according to what is in my best health interests. If there is ever a situation where I strongly desire a certain treatment that my provider does not feel is healthy for me, I recognize that I may not be able to receive this treatment from Hope Within. I also realize that there are other health centers in both Dauphin and Lancaster Counties where I could receive care, even without health insurance.
2. Information ReleaseFrom time to time, Hope Within may need to contact me. If I am not available, I authorize the following contact person(s) to discuss my financial and/or medical information to/with Hope Within Community Health Center:

   
   

3. Patient Assistance Programs (PAPs) AgreementsHope Within Community Health Center is also a resource for qualifying patients to obtain medication from Patient Assistance Programs (PAPs) sponsored by large pharmaceutical companies. When a patient meets the Hope Within eligibility requirements, your advocate applies at regular intervals to these companies on the patient’s behalf to obtain prescription medication. In most cases, the patients’ signature is required, and in all cases, the prescribing physician’s signature is required on each application. I hereby:
   • Give my permission to Hope Within Community Health Center to sign my name to PAP applications for medications prescribed for me by my physician. I understand that I may revoke this authorization at any time. I will then assume responsibility for signing my own forms.
   • Give my permission for Hope Within to send the required medical or financial supporting documentation to the referred organizations for the PAP programs.
   • Give my permission for these PAP-related pharmaceutical companies to run credit checks on me as needed in order to secure medications I may require.
   • Give my permission to Hope Within Community Health Center to collect the necessary information, process, share and forward my request for medications to pharmaceutical companies. My signature also authorizes Hope Within to complete, sign and execute PAP applications on my behalf. If I provide incorrect information, I will be held responsible.