Please include wages, tips,
unemployment, social security, disability, retirement, alimony, capital gains, investments, royalty,
rental
Note: You are required to submit proofs of your Identification, Residency and Income along with this Eligibility Application. See below for instructions. Alternatively, photographs of requested documents can be emailed to annemarie.mcalester@hopewithin org or faxed to 717-367-1160
Acceptable Proofs of Identification (provide one of the following documents below)
-Copy of valid PA driver’s license or PA ID card (can also serve as proof of
Residence if address is current)
-Copy of passport
-Copy of Alien Registration card
Acceptable Proofs of Residency (Provide one of the following documents below)
-Copy of valid PA driver’s license or PA ID card (can also serve as
proof of Identification if address is current)
-Copy of utility bills
- Copy of rent receipt or written statement from a non-relative landlord
- Copy of mortgage receipt
- Envelope of mail postmarked within the last 3 months with applicant’s name
and address
Acceptable Proofs of Income (provide one document for each type of income for your
monthly gross income)
-Copy of pay stubs, checks, and award letters from the last 30 days
-Copy of Social Security award letter
-Copy of Worker’s Comp check, check stub or current award notice
- Copy of award statement for unemployment
- Copy of pension award letter
- A written statement from person or agency providing money or making payments for you
- If you are self-employed, we need your estimated income and expenses for the
last quarter and a copy of last year’s federal tax return
-Copy of the most recent year’s tax return
- 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 right 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 Dauphin, Lancaster and Lebanon Counties where I
could receive care, even without health insurance.
C. Patient Assistance Programs (PAPs) Agreements: Hope 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 patient's’ 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 checked agreement also authorizes Hope Within to complete, sign and execute PAP applications on my behalf. If I provide incorrect information, I will be held responsible.
