Become a Patient - Community Care Clinic

Name*
First Middle Last
Sex*
- Male
- Female
Date of Birth*
MM
DD
YYYY
Are you a Rowan County resident?*
- Yes
- No

Application Instructions for Services
Eligibilty Requirements
- Patients must be uninsured.
- Patients must be a Rowan County resident.
- Patients cannot have a household income exceeding 200% of the Federal Poverty Level (currently $23,760 for individual and $48,600 for a family of four).
Directions for Application
- Complete the Application For Services and Patient Health History Form. If you are self-employed, you must also complete the Self-Employed Statement of Income Form. These forms can be returned at any time the clinic is open. Incomplete application forms may cause a delay in services. This Eligibility Requirements and Directions For Application Form explains the items to bring to the Enrollment Appointment for verification of eligibility.
- Your application will be reviewed by the clinic staff. Please be sure that you have given a current phone number at which you can be contacted. You should expect to hear from the clinic within 5-7 business days of completing your application. If you are approved, you will be scheduled for an Enrollment Appointment. During the Enrollment Appointment, you will not see a doctor.
- The following information must be brought to the Enrollment Appointment. Copies of the information below will be made and you will complete any other forms needed for your chart. Your paperwork will be processed and you will be enrolled as a patient. Upon completion, your first doctor’s appointment will be scheduled.
Proof of income for patient Pay stubs for the last three months, verification from ESC for unemployment, monthly pension statement, letter from social security showing monthly benefit for retirement or SSI for dependent, child support, etc. Bank statement showing direct deposit cannot be used for proof of income. If you are applying for disability, we will need a letter of verification of claim from the Social Security Administration or letter from your lawyer.

Proof of income for other household members Pay stubs for the last three months, verification from ESC for unemployment, monthly pension statement, letter from social security showing monthly benefit for retirement or SSI for dependent, child support, etc. Bank statement showing direct deposit cannot be used for proof of income.

Income tax return or 4506-T form If you filed taxes for the most recent tax year, we need either a copy of the 1040 or a transcript of you return. A transcript can be requested by calling 1-800-908-9946 or on-line at IRS.gov. If you did not file taxes, you will need to complete the attached 4506-T form.

Proof of Identification You will need a valid North Carolina driver’s license or state identification card with a Rowan County address. You will also need to bring your social security card or a letter from the Social Security Administration with verified social security number.

Proof of Residency You will need to provide one recent document providing residency in Rowan County. Accepted documents include utility bill (gas, water, electricity) and/or rental or lease agreement.

Medicaid denial OR written statement from Social Services (Letter of Inquiry) stating you are not eligible for Medicaid less than 6 months old. If Social Services denies your Medicaid because you have not given them the information they requested, you must go back and complete the application before eligibility can be approved. If you have applied for Medicaid, but have not received an answer, we need proof of an application. We have included a letter that you can take with you to Social Services to apply for Medicaid.

The clinic requires a $10.00 non-refundable administrative fee per quarter. Patients can pay the $40 for the year or $10 per quarter. Patients who do not comply will be locked out and can unlock for $10 (maximum one time per year).

Please allow 5-7 business days for your application to be reviewed.

Click Here to download the letter.
Please indicate you have read and understand the above information before continuing:
- I understand
- I do not wish to continue

Terms of Service & Informed Consent
Please read the following information. After reading each section, please indicate your agreement by selecting the "I understand" checkbox at the bottom of each page.
Mission/Vision Statement Our mission is to provide primary medical and dental care and prescription medications to qualified underserved and uninsured adults in Rowan County. Our vision is to ensure that healthcare is available to all Rowan County residents through service provision and/or collaboration with other resources.

Eligibility All patients must qualify for services upon initial visit and every 90 days thereafter. Proof of eligibility for 90 day update includes the following:
- All household income (wages, unemployment, pension, Social Security retirement, Social Security disability, child support) (every 90 days)
- A Medicaid denial from the Department of Social Services. If you have Family Planning Medicaid, we must have the letter stating that is for family planning only (annually) and a copy of the Medicaid card.
- If you are actively seeking disability, this must be verified by a letter from the Social Security Administration or your attorney (every 90 days).
- 1040 Form for federal taxes or 4506-T form (annually)
- Beginning January 1, 2018, the clinic will ask for a $10.00 non-refundable administrative fee per quarter. Patients can pay the $40 for the year or $10 per quarter.
- After all eligibility is updated and the administrative fee has been paid, a yellow eligibility card will be issued to the patient for 90 days. This card must be presented to receive medical, dental and pharmacy services each time services are rendered and/or a prescription is picked up. If you do not update, your eligibility will be locked and you will not be able to pick up your prescriptions or receive services until your eligibility is updated.
- $10 non-refundable administrative fee
Eligibility requirements are set by what drug companies require in order for patients to receive free medications. The following information is needed for this program: name, SSN, DOB, income, address, income taxes or 4506-T form, Medicaid denial, phone number and medical records. Additional documents may be required if requested by the drug companies.
Please indicate you have read and understand the above information before continuing:
- I understand
- I do not wish to continue

Terms of Service & Informed Consent - Section 2
Please read the following information. After reading each section, please indicate your agreement by selecting the "I understand" checkbox at the bottom of each page.
SERVICES: It is the purpose of the Community Care Clinic of Rowan County to provide a high standard of care. The CCC is a primary care clinic and there will be limitations on services we can provide. The Board of Directors guides the clinic in the mission of providing the highest quality of patient care possible.

APPOINTMENTS: Patients are to call the Community Care Clinic at 704-636-4523 in order to schedule an appointment. Please call the clinic for a sick appointment before going to the Emergency Department. All scheduled appointments are given on a first call/first come basis.

REFERRALS: Visits to the Community Care Clinic are free of charge. There is no guarantee for any free service outside of the clinic. This includes referrals, diagnostic testing or screenings. If the physician makes a referral, a consent form will be required for that visit; however, this does not mean the service will be free (Many physicians will take a decreased rate if a patient is able to pay up front). It is your responsibility to confirm cost with all outside referrals.

EMERGENCY ROOM VISITS / HOSPITAL ADMISSIONS: Should a patient require emergency services, or an admission to any hospital, it is the responsibility of the patient to make that arrangement. Do not list the specific physician and/or dentist seen, but state the Community Care Clinic is your primary care facility. Most clinic physicians and dentists are volunteers and are not to be considered as your primary physician/dentist.

NO PRESCRIPTIONS CAN BE PICKED UP WITHOUT A PHARMACIST ON DUTY!
(This is a North Carolina state law)

The pharmacy is open Monday–Thursday from 9am-Noon and 1pm-4pm. No prescriptions can be picked up on Friday.

Prescription refills must be called in 7 DAYS prior to pick-up. Refill requests may be phoned-in 24 hours a day using the refill line. Please DO NOT wait until you are out of medicine to request refills.

You must bring your yellow eligibility card to pick up your prescriptions. If you need to send a friend or a family member to pick up your medicine, please send your yellow card with them so we know that they have your permission to pick up your prescriptions.

Please note that you will occasionally receive mail from drug companies stating that you have been accepted into their program and a 90 day supply of medications was shipped directly to your physician. All medications should be shipped directly to the Community Care Clinic, not to your home. Do not complete any forms for medications you receive through the mail. Any telephone calls from the drug companies should be directed to the clinic. Clinic staff will complete all necessary paperwork for you. Please bring any medications and paperwork to the clinic that you receive at home.

If you receive any of the following from drug companies at home, you must notify the CCC pharmacy staff IMMEDIATELY:
- Medications
- Rejected applications/denial letters from drug companies
- Request for additional information
Please indicate you have read and understand the above information before continuing:
- I understand
- I do not wish to continue

Terms of Service & Informed Consent - Section 3
Please read the following information. After reading each section, please indicate your agreement by selecting the "I understand" checkbox at the bottom of each page.
Any visit to an outside physician, including any Emergency Room visits, must be reported to the Community Care Clinic immediately. Failure to do so may result in discontinuation of services.

Weapons and illegal substances are not allowed on the premises. If you are in possession of either, the police will be informed and you will be immediately discharged permanently from all clinic services.

The Community Care Clinic reserves the right to refuse service to anyone under the influence of drugs, alcohol, or exhibiting disruptive behavior. This includes clinic visits and telephone calls to the Community Care Clinic. Rude, vulgar or angry behavior will not be tolerated.

Patients are expected to arrive on time. Please make every attempt to leave children at home. Children are not to be left unattended in the waiting area. Eating and drinking are not allowed in patient areas.

Please do not bring your cell phone into the patient treatment areas. If you must, it is required that they be turned off. No exceptions.

The volunteers, including doctors, are not paid employees of the clinic. They are here to serve you and are donating their time without payment of any kind to help you. There will be many different volunteers working in the clinic, and they will be here when their time permits. While it is anticipated that all volunteers, professional and non-professional, will use their skill and judgment to the best of their ability and in a kind and courteous manner, the clinic cannot control their actions.

Physicians volunteer on a rotating basis; therefore they do not have access to a patient’s medical records. If a patient contacts any volunteer physician or dentist for services outside of the Community Care Clinic setting, they will be in breach of Community Care Clinic guidelines and subject to dismissal for services provided by the clinic.

SUSPENSION OF SERVICES: Failure to comply with a physicians’ treatment plan may result in dismissal from the clinic. This may include:
1. Seeing two primary care physicians
2. Failure to attend screening/referral appointments (this includes ALL appointments)
3. Failure to get lab work done or non-compliance
4. Falsification of any information provided (failure to report changes in income, ability to obtain health insurance through a spouse, or moving/living in another county)
5. If you are a no show for any appointment without calling to cancel in advance, you will not be eligible for any clinic services for 6 months. If you reschedule an appointment more than three times without attending in a 12 month period, you will be subject to no service for 6 months. A letter will be sent to your home address on record to explain suspension of service (you can unlock for $10 – maximum one time per year).
6. If you are caught selling or giving others your medications, test strips or anything else prescribed for you, you will be discharged PERMANENTLY from the clinic.
7. Failure to pay $10 non-refundable administrative fee quarterly
We are a non-profit organization that operates through the use of paid/volunteer professionals, skilled support staff and donations from the community. We are not a state, federal or county program. Please consider making a donation each time you visit the clinic. This will be used to offset the operational expenses of the clinic. You are not paying for your services, only helping to keep the clinic open to serve others as well as yourself.

I acknowledge that the above has been explained to me to my satisfaction and I voluntarily consent to be examined and evaluated by the medical staff at the clinic. I also agree for routine tests to be done as necessary and treatment as indicated. The physician and/or nurse will discuss with me any treatment plan considered. I will comply with all services provided and understand my consequences if I do not.

THE COMMUNITY CARE CLINIC IS HERE TO PROVIDE FREE PRIMARY MEDICAL AND DENTAL CARE TO PATIENTS. There will be times that we are unable to treat your need if it is out of the scope of our primary practice.
Please indicate you have read and understand the above information before continuing:
- I understand
- I do not wish to continue

List total monthly household income amounts:
Salary/wages Social Security Unemployment Pension
Disability Worker's Comp Self Employment Other
Number of adults in household:*
Number of children in household:*

Services Requested
- I need to see a doctor at this clinic.
- I need to see a dentist at this clinic.
Since you're applying for medical and dental services, what is your immediate need?
- Medical
- Dental
Reason for needing to see a dentist?
- Toothache
- Cavities
- Extraction
- Broken Tooth
- Other
Please explain:

Have you recently been in the hospital or visited the ER for any illness or injury?*
- Yes
- No
Approx. Date Place Reason

(Click the + icon to add more rows)
Do you have a physician that you see regularly?*
- Yes
- No
Physician Name & Phone Number
Name Phone Number
Please list any food or medication allergies:
Please list any medications you are taking now or should be taking on a regular basis:

In the last year, have there been any major life changes that you would like to make us aware of?
Applicant Signature*

GETTING STARTED

REQUIREMENTS

The patient must be:

Uninsured,

a Rowan County Citizen,

at least 19 years of age,

with an income level not
exceeding 200% of the Federal Poverty Level (Currently $23,540 for individual and $48,500 for a family of four),

and not currently receiving Medicaid, Medicare, or Disability benefits.

Application Instructions for Services

Eligibilty Requirements

Directions for Application

Terms of Service & Informed Consent

Terms of Service & Informed Consent - Section 2

Terms of Service & Informed Consent - Section 3

Patient Health History

DOWNLOAD APPLICATION PACKET:

Print and mail, or bring in, this packet to the clinic.
315G Mocksville Ave, Salisbury, NC 28144

SUBSCRIBE

Approx. Date	Place	Reason

GETTING STARTED

REQUIREMENTS

The patient must be:

Uninsured,

a Rowan County Citizen,

at least 19 years of age,

with an income level not exceeding 200% of the Federal Poverty Level (Currently $23,540 for individual and $48,500 for a family of four),

and not currently receiving Medicaid, Medicare, or Disability benefits.

Application Instructions for Services

Eligibilty Requirements

Directions for Application

Terms of Service & Informed Consent

Terms of Service & Informed Consent - Section 2

Terms of Service & Informed Consent - Section 3

Patient Health History

DOWNLOAD APPLICATION PACKET:

Print and mail, or bring in, this packet to the clinic. 315G Mocksville Ave, Salisbury, NC 28144

SUBSCRIBE

with an income level not
exceeding 200% of the Federal Poverty Level (Currently $23,540 for individual and $48,500 for a family of four),

Print and mail, or bring in, this packet to the clinic.
315G Mocksville Ave, Salisbury, NC 28144