Financial assistance options for uninsured and underinsured families and individuals

To determine your eligibility for support programs and sliding fee scales, we will need some information from you when you come for your intake appointment. Please bring the following information. If any information is missing, your intake appointment will be rescheduled. If you have questions, please call your local HealthLinc clinic and ask to speak with the Intake Coordinator.

• Birth certificate or passport
• Photo identification (driver’s license, state ID, school ID)
• Social security number
• Medicaid, Medicare or commercial insurance card (if applicable.) If a child has been denied Medicaid, bring the denial letter
• Proof of current resident (e.g. utility bill, bank statement, phone bill)
• Last year’s federal tax return (1040 form) or waiver of filing (From 4508-T)
• Paycheck stubs for most recent 30 days (if employed.) If you (or someone in your household) works but do not have pay stubs, provide a signed letter from your employer on the employer’s letterhead (with contact name and phone number) and the amount you are paid.
• Proof of any other sources of income: unemployment, Social Security, pension/401(k)/annuities, worker’s compensation, disability, self employment profit or loss, etc
• If you have no income, please bring a “food and shelter” letter from the person with whom you are living (this is a letter signed by that person stating that they are providing you with food and shelter). This letter must be dated, provide the address, and be signed by the person with whom you are living.

All Forms in Espanol

Privacy Practices

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Privacy Practices Psychiatry Addendum

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