- Please return this packet with the needed information found on the second page. - DON T forget anything or it will delay the application!

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1 IU Health La Porte Community Health Center IU Health La Porte Dental Center 400 Teegarden Street, Suite B 400 Teegarden Street, Suite A La Porte, Indiana La Porte, Indiana Phone (219) Fax (219) Phone (219) Fax (219) Welcome to the application process for Indiana University Health La Porte Community Health Center and Indiana University Health La Porte Dental Center! - Please return this packet with the needed information found on the second page. - DON T forget anything or it will delay the application! - If you have Medicaid, Medicare, HIP or insurance, DO NOT COMPLETE THIS FORM. Please call our office for further information. - You must be a La Porte County resident to qualify for sliding scale services. If you are not a resident, please call our office for referrals. - If you live in Michigan City, we can only offer you dental services. - If you own rental property, you are NOT ELIGIBLE for services. Please call our office for referrals. - We are currently unable to provide medical services for children who are Medicaid eligible. ** PLEASE BE AWARE: YOU WILL HAVE 30 DAYS TO TURN IN ANY MISSING INFORMATION. AFTER 30 DAYS, INCOMPLETE APPLICATIONS WILL BE DISCARDED

2 This is an application for reduced rate health care, medications and dental care provided by the Indiana University Health La Porte Hospital. Please bring in the following information: o Most recent Federal Tax Return. Please attach all of the schedules. If you did not file taxes in the last year, please come sign a release so we can confirm this with the IRS. o Last 3 months (if possible) of paystubs. If you cannot provide this, we MUST have a Work History. This can be obtained from WorkOne (unemployment office located at 300 Legacy Plz # ). This is a free service, but you must provide a picture ID and a Social Security Card. o Two most recent bank statements. o Picture Identification and Social Security Card. o Proof of address, which must include any one of the following: Nipsco bill, water bill, lease or mortgage. o Proof of any other type of money/support you receive: unemployment, child support (letter from court if not receiving child support), SSI, SSD, Social Security, Pension, TANF, foodstamps and/or HUD Housing. o Proof that you or any other household members are applying for Social Security Disability. o We must have proof of income or a work history (if not working) for EVERY household member over 18 years of age. ** Household members are defined as people living in your home regardless of your relationship. As part of the application process, IU Health La Porte Community Health Center does have the right to obtain a Credit Report and Public Records Search. The processing time generally takes 30 days or less from the date received. You will be notified of your determination in writing. You will not be seeing the Doctor or Dentist at this appointment. You can schedule a medical or dental appointment following your meeting with the Social Worker. If you have any questions when filling out your application, please feel free to contact us at (219) Thank you, IU Health La Porte Community Health Center - 2 -

3 CONFIDENTIAL FINANCIAL EVALUATION PLEASE COMPLETE THIS FORM FULLY AND RETURN IT. APPLICATIONS CANNOT BE PROCESSED WITHOUT HOUSEHOLD INCOME VERIFICATION. IF YOU HAVE NO INCOME, PLEASE PROVIDE EXPLANATION OF HOW YOUR LIVING EXPENSES ARE PAID AND PROVIDE PROOF OF INCOME FROM THE PERSON SUPPORTING YOU. Date Name (FIRST) (LAST) M.I. Have you been a patient here before? Date of Birth Address _ Telephone City State Zip Social Security No. How long have you lived at this address? Emergency Contact Telephone Martial Status Ethnicity Level of Education Insurance? Yes Medicaid? Yes Medicare? Yes Veteran? Yes No No No No Employer: Name Address Phone Total number of persons in the household Please provide information for ALL other household members, including children and members not applying for services. (If a household member is not applying for our services, you may omit their Social Security number.) If your household has more than 6 members, please attach a separate piece of paper. 1. Name (First) (Last) (MI) Insurance? Yes No 2. Name (First) (Last) (MI) Insurance? Yes No Social Security Number Medicare? Yes No - 3 -

4 3. Name (First) (Last) (MI) Insurance? Yes No 4. Name (First) (Last) (MI) Insurance? Yes No 5. Name (First) (Last) (MI) Insurance? Yes No 6. Name (First) (Last) (MI) Insurance? Yes No HOUSEHOLD INCOME FROM OTHER SOURCES AMOUNT PER MONTH Pension/Social Security/Social Security Disability Income you receive for property you own.. Stocks/Bonds/Annuities/Interest Unemployment or Worker s Compensation.. Alimony. Child Support. Private Disability School Loan - 4 -

5 CHARITABLE ASSISTANCE Food Stamps/TANF/Foster Care/Township Trustee/Church Project SAFE/Lunch Programs/Etc.... TOTAL MONTHLY GROSS INCOME ASSETS Cash on Hand Checking Account Balance Bank (name) Health Savings Account 401 (K), 403 (b), or Other Retirement Savings. Investments or Other Securities Savings Account Balance Bank (name) Stocks/ Bonds/IRA, Certificate of Deposit Bank (name) Real Estate (Primary Residence)..Value Other Real Estate Location Value Vehicles Year/Make/Model Value Year/Make/Model Value TOTAL ASSETS: $ OTHER CIRCUMSTANCES WE SHOULD CONSIDER IN ASSISTING YOU: * PLEASE INCLUDE PROOF OF ADDRESS AND VERIFICATION OF INCOME (see first sheet) I certify that all information is true and complete to the best of my knowledge. I understand that the information provided will be verified and treated as personal and confidential. I authorize the release of any and all information from the Indiana Division of Family and Children Services. I understand that any misrepresentation of information may result in permanent termination of IU Health La Porte Community Health Center and IU Health La Porte Dental Center eligibility. I also understand that I will be liable for repayment of any services rendered at any affiliate if the above information is given under false pretenses. Signature Date - 5 -

6 CONSENT I hereby authorize Indiana University Health La Porte Hospital through LexisNexis Risk & Information Analytics Group, Inc., and their designated agents and representatives to access my financial background through a consumer report and/or investigative consumer report to be generated for purposes of determining whether I am eligible for free or reduced health care services at the IU Health La Porte Community Health Center. I understand that the scope of the consumer report/investigative consumer report may include, but is not limited to, the following areas: verification of social security number; current and previous residences; credit history and reports; birth records; motor vehicle records to include traffic citations and registration; and any other public records or to conduct interviews with third parties relative to my character, general reputation, personal characteristics or mode of living. Indiana University Health La Porte Hospital reserves the right to refuse health care services based on the financial or personal information provided by LexisNexis Risk & Information Analytics Group. I may request a copy of any of my financial information used by Indiana University Health La Porte Hospital to determine whether I am qualified for health care services at IU Health La Porte Community Health Center. I hereby release Indiana University Health La Porte Hospital, LexisNexis Risk & Information Analytics Group, Inc., and its agents, officials, representatives, or assigned agencies, including officers, employees, or related personnel both individually and collectively, from liability to the extent permitted by law for damages of whatever kind, which may, at any time, result to me, my heirs, family, or associates because of compliance with this authorization and request to release. I have read, I understand and agree to each of the disclosures, authorizations, directions and indemnifications. * Every household member age 18 and older must sign this form. Signature Date Signature Date Signature Date Signature Date - 6 -

7 IU Health La Porte Community Health Center IU Health La Porte Dental Center 400 Teegarden Street, Suite B 400 Teegarden Street, Suite A La Porte, Indiana La Porte, Indiana Phone (219) Fax (219) Phone (219) Fax (219) AUTHORIZATION FOR RELEASE OF INFORMATION We are required to verify earned income to determine your eligibility for this program. We will be contacting your employer, with your authorization. I authorize the release of information regarding wages, health/dental care coverage and certain wage deductions to IU Health La Porte Community Health Center for the purpose of establishing my eligibility for the health and/or dental care program. This authorization is valid for 365 days after the date of the signature. Signature of wage earner Date - 7 -