Tiffany Hemphill

Detail-oriented individual with exceptional communication and project management skills. Proven ability to handle multiple tasks effectively and efficiently in fast-paced environments. Recognized for taking proactive approach to identifying and addressing issues, with focus on optimizing processes and supporting team objectives.

• Applicant/Guarantor Name: Last First Middle Initial
• Date of Application:
• Date of Birth: Social Security #: Email address:
• Home Phone: ( ) Ok to leave voicemail? Yes No
• Cell Phone: ( ) Ok to leave voicemail? Yes No
• Work Phone: ( ) Ok to leave voicemail? Yes No
• Best number to use: Home Cell Work
• Address: Street City State ZIP
• Marital Status: Single Married Divorced Widowed
• Spouse’s Name: Last First
• Family Information
• Include any dependent children, spouse, and any individuals over the age of 18 for whom the applicant has legal responsibility to support living in the home, or children attending college up to the age of 26. Please do not include the applicant
• Full Name Age Date of Birth Social Security # Source of Income Relationship to Applicant
• Family Size and Income Information
• Please see back of form for required documentation of identity, income, and family size.
• Total Number in Family (including applicant): Total Monthly Income:
• Declaration by Applicant/Guarantor
• I have reviewed this form and certify that information provided and documents attached herein by me are true and correct to the best of my knowledge. Should any of this information prove to be false, all financial assistance awarded will be reversed, and I accept responsibility for full payment of the amount due. I also agree to accept payment responsibility for any amount due from me for myself or any other member of the eligible persons listed in this application as a result of any partial financial assistance, which may be awarded.
• Applicant/Guarantor’s Signature: Date:
• Review (OFFICE USE ONLY)
• Decision: Approved Denied Level (if approved): 1 2 3 4 5 Effective Date: Term Date:
• Reviewer’s Signature: Date:
• Authorized Official’s Signature: Date:
• The minimum nominal fee of $25 for a medical visit, $35 for a dental visit, and $5 for a behavioral health visit is due at the time of registration for your first visit. The minimum nominal fee is per service, per patient pending review and determination of this application. If you do not submit this application with all required supporting documents within 10 business days, your application will be denied and you will be charged the full fee for services provided. A determination notice will be sent to the Applicant/Guarantor after review and determination of this application. Appointments for future visits should be made after receipt of an approval notice or as indicated by your provider.
• Sliding Fee Discount Program Eligibility Information
• Family size: In addition to the applicant, a family includes any dependent children, spouse, and any individuals over the age of 18 for whom the applicant has legal responsibility to support living in the home. Children attending college up to the age of 26 are also included in determining total number of individuals in a household/family. For individuals over the age of 18 for whom the applicant has legal responsibility for supporting, court documents must be presented as verification of support. For children over the age of 18 attending college, a current school schedule or transcripts dated within the last 45 days may be used to verify support.
• Photo ID: The applicant must provide a state ID, state driver’s license, passport, CityKey, matricula consular, or similar identification from other countries of origin.
• Income: Applicant must provide a copy of the most recent year’s U.S. Individual Income Tax Return or a copy of the most recent pay stubs, child support statements, unemployment benefits statements, and/or Social Security benefits statements for all family members over the age of 18. Line 9 of the most recent year’s U.S. Individual Income Tax Return will be used for determination of gross income for both employed and self-employed applicants. If paystubs are provided they must be dated within the last 45 days and cover at least a 4 week period. If no pay stubs are available and the applicant is employed, the applicant’s employer can provide a letter, on company letterhead, indicating hours worked per week, current wage, the frequency of pay, and contact information of the employer. If the applicant is self-employed and cannot provide the most recent year’s U.S. Individual Income Tax Return, the applicant can complete a self-declaration form.
• Applicants declaring no job and/or no income will be required to sign a self-declaration form and, if eligible, will be placed at Level 1 for one year. Self-declared applicants with no income must provide information about how they support themselves for food and housing. Applicants declaring they are self-employed that cannot produce the most recent year’s U.S. Individual Income Tax Return will be placed in the appropriate level for one year.