Healing Hands Medical & Dental Ministry Pre

Healing Hands Medical & Dental Ministry
Pre-qualification Questionnaire
Healing Hands is a free clinic providing primary care medical services and emergency dental services to
uninsured residents of Duval County that meet financial criteria. If you reside in Duval County, are uninsured
and in need of these services, please complete both sides of this questionnaire in full, attach the required
document(s) and return to the clinic for evaluation. Applications WILL NOT be considered without required
documentation attached.
DATE:
______ /______ /______
NAME:
______________________
Last
ADDRESS:
_____________________
___________
First
MI
_____________________________________
____________________ _____________
Street
PHONE #:
______________________
Home
DOB:
Day
Zip
_______________________ ______________________
Cell
______ / _____ / _____
Month
City
Veteran?
Other
YES
NO
Year
WHICH SERVICE ARE YOU IN NEED OF?
MEDICAL
DENTAL
WHAT IS YOUR MOST IMMEDIATE NEED? Please write a brief but detailed description explaining the exact
reason including symptoms, so that we can determine how we may be able to assist you.
Please note we are UNABLE to assist with crowns, bridges, denture repair or dental hygiene at this time.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
DO YOU HAVE:
MEDICAL INSURANCE
DENTAL INSURANCE
MEDICARE
MEDICAID
HOW MANY FAMILY MEMBERS LIVE IN THE HOME? LIST THEIR NAMES AND HOW THEY ARE RELATED TO YOU:
NAME
AGE
HOW ARE THEY RELATED TO YOU?
TURN OVER
HAVE YOU EVER BEEN A HEALING HANDS PATIENT?
NO
YES (DATE LAST VISIT: _____________)
WHAT WAS THE TOTAL INCOME RECEIVED IN THE LAST FOUR WEEKS FOR YOU AND YOUR SPOUSE?
Include all employment, unemployment, social security, child support, etc.
$____________________ [Proof of this amount must be attached in the form of copies (i.e. Pay stubs,
Unemployment statements, Social Security statements etc., for the past four
weeks for questionnaire to be reviewed.]
IF $0, WHO IS SUPPORTING YOU? (COVERING YOUR ROOM AND BOARD EXPENSES)
______________________________________ [If 0 income above, you must attach a NOTARIZED letter of
Last Name, First Name
support written by the person who is supporting you stating
that they are providing you with roo.vfm and board but no
help with medical or dental expenses or your questionnaire
will not be reviewed.]
RETURN QUESTIONNAIRE AND ATTACHMENTS TO HEALING HANDS BY ONE OF THE FOLLOWING:
MAIL: HEALING HANDS
5126 TIMUQUANA RD
JACKSONVILLE, FL 32210
FAX: 904-777-0012
IN PERSON: HEALING HANDS
5126 TIMUQUANA RD
TUES OR THUR 3PM-7PM
Most FRIDAYS 9AM-5PM
** PLEASE NOTE THAT ATTACHMENTS SHOWING PROOF OF INCOME OR PROOF OF SUPPORT ARE
REQUIRED FOR EVALUATION. IF THEY ARE NOT INCLUDED YOUR QUESTIONNAIRE WILL NOT BE REVIEWED
AND YOU WILL NEED TO RESUBMIT THE QUESTIONNAIRE WITH ATTACHMENTS.
FOR OFFICE USE ONLY
DATE QUESTIONNAIRE RECEIVED: ____ / _____ / _____
PRE-QUALIFIED?
YES
NO
DATE CONTACTED: 1) _____ / _____/ _____
POI
EXISTING PT?
2) _____ / _____/ _____
LOS
YES
INCOMPLETE
NO
3) _____ / _____/ _____
APPOINTMENT DATE: _____ / _____ / _____
CONTACTED BY:
MEDICAL COORDINATOR
DENTAL COORDINATOR
TURN OVER