Please review our full Eligibility Criteria and required

Eligibility Criteria
To qualify for services from the Polizzi Clinic, an individual must meet the following criteria:
□
Be uninsured
□
Household income must fall within 150% of current Federal Poverty Guidelines
For 2015:
Number of Family
Members
1
Gross Annual
Income
2
3
4
5
6
7
8
Gross Monthly
Income
$17,655
$1,471
$30,135
$2,511
$23,895
$36,375
$42,615
$48,855
$55,095
$61,335
Approx. Full-Time
Hourly Income
$8.49
$1,991
$11.49
$3,031
$17.49
$14.49
$3,551
$20.49
$4,071
$23.49
$4,591
$26.49
$5,111
$29.49
□
Either be English-speaking or call ahead to arrange for a translator
□
Not have a Substance Use diagnosis as the primary diagnosis
□
Not have a Severe Personality Disorder
□
Should be 6 years of age or older (younger taken on a case-by-base basis)
Required Documentation
Please bring at least one of these items to verify income:

Most recent tax return statement

Most recent W-2 statement(s) from employment

Most recent paycheck stubs (reflecting one month of pay)

Proof of Food Stamps or other state assistance

Letter from Employer (if paid in cash) including contact information, hourly rate, hours per week

Last 3 months bank statements
Current as of March, 2015
Polizzi Clinic | 515 E 4500 S, Suite G220, Salt Lake City, Utah 84107 | 801-277-7740