Between the ages of birth and 65?
Could ELIGIBILITY
you
be a patient
Medical
Home?
CRITERIA
PROVING
YOUR ELIGIBILITY
Could
you
be at a Grace
patient
at Grace
Medical
Home?
ARE YO
Earning at or less than 200% of the Federal
BELOW
Grace Medical Home serves the working uninsured
Proof of Id
WHAT
DO Line?
YOU (See
NEED
TO BRING
YOUR
Poverty
Federal
Poverty TO
Chart)
of
Orange
County,
Florida
who
reside
at
or
below
FEDER
ELIGIBILITY CRITERIA
PROVING YOUR ELIGIBILITY
ARE YOU AT OR
ELIGIBILITY APPOINTMENT?
Currently employed,
OR have
been employed
200%
of the federal poverty
line.
ELIGIBILITY
CRITERIA
PROVING
YOUR
ELIGIBILITY
ARE YO
BELOW
200% THE
Grace Medical Home
serves the working uninsured
WHAT DO YOU NEED TO BRING
TO YOUR
within
the
last
six
months,
OR
a full-time
student,
Patient Eligibility
Provide
Proof
Through
of Orange County,
Florida
who
reside
at
or
below
FEDERAL
POVERTY
LINE? BELOW
ELIGIBILITY
APPOINTMENT?
Grace YOU…
Medical Home serves the working
uninsured
ARE
OR a DO
single
parent
of a TO
child
under TO
the YOUR
age of 6?
Criteria
the
Following
Documents
WHAT
YOU
NEED
BRING
200% of the federal poverty line.
Number in
of Orange County, Florida who reside at or
below
FEDER
Patient Eligibility
Provide
Proof Through
ELIGIBILITY
APPOINTMENT?
Federal Poverty
Chart
Currently living in Orange County, Florida?
Uninsured
and
not enrolled • in
government
assisted
your Fami
ARE YOU… 200% of the federal poverty line.
Criteria
the Following Documents
Valid Florida Driver’s
Living
in O
Number
in
200% Share
Poverty of 200% Poverty
Unit
healthcare programs (such
as
Medicaid,
License
or Photo
ID
the ages
of birth and 65?
for at least
Currently living in Between
Orange County,
Florida?
Patient
Eligibility
Provide
Proof
Through
your
Family
Annual
Monthly
• Valid Florida Driver’s
Cost, Medicare
or VA Benefits)?
Threshold
Threshold
1
Criteria
the
Following
Documents
• Unit
Social
Security
Card
License or Photo
ID
Between the ARE
ages
of YOU…
birth at
and or 65?
Earning
less than 200% of the Federal
Number i
1 of the
$23,760
$1,980
•
Social
Security
Card
Proof
of
Identity
•
Green
Card
2
If
you
answered
“YES”
to
each
above
criteria,
Currently
living
in Federal
Orange
Earning at or less
than 200%
of the
Poverty
Line?
(See
Federal County,
Poverty Florida?
Chart)
your Fami
Valid Certificate
Florida $32,040
Driver’s
Proof of Identity
• Green Card
2
$2,670
Poverty Line? (See Federal Poverty Chart)
• • Birth
it is highly likely that you could
be a patient
at ID
Unit
3
License
or
Photo
Between employed,
the ages of OR
birth
and been
65? employed
• Birth Certificate
Currently
have
3
$40,320
$3,360
•
Voter’s
Registration
Currently employed, OR have been employed
Grace
Medical
Home.
• Voter’s Registration
1
4
•
Social
Security
Card
the
six months,
OR of
a full-time
student,
4
$48,600
$4,050 Earning les
Card
Earning
at last
or
less
than
200%
the Federal
within the last six within
months,
OR
a full-time
student,
Card
Proof
of
Identity
•
Green
Card
2 of th
OR
parent
of
a of child
under the
age of 6?
OR a single parent
of a a single
child
under
the age
6? Poverty
5
$56,880
$4,740 200% 5
Poverty
Line?
(See
Federal
Chart)
Grace Medical Home?
Uninsured and not
enrolled in and
government
assisted in government assisted
Uninsured
not ELIGIBILITY
enrolled
Living in Orange County
PROVING
YOUR
Currently
employed,
OR have
been employed
healthcare programs (such as Medicaid, Share of
for at least two months
healthcare programs
(such OR
as Medicaid,
of
six months,
a full-time Share
student,
Cost,
Medicare
or VA
Benefits)?
WHAT
DO
YOU
NEED
TO
BRING
TO
YOUR
OR
a
single
parent
of
a
child
under
the
age
of
6?
If you answered “YES” to each of the above criteria,
within
the last
Cost, Medicare or
VA Benefits)?
it is highly likely If that
you
could be a patient
at to each of the above criteria,
ELIGIBILITY
APPOINTMENT?
you
answered
Uninsured
and “YES”
not enrolled
in government assisted
Grace Medical Home.
it is healthcare
highly likely
that you (such
could as
be Medicaid,
a patient
at
programs
Share
of
Earning
less than
Patient
Eligibility
Provide
Proof
Through
200%
of the Federal
Grace
Medical
Home.
Cost, Medicare or VA Benefits)?
Poverty Line
Criteria
the Following Documents
(See Federal
If you answered “YES” to each of the above
criteria,
Poverty Chart)
it is highly likely that you
could Florida
be a patient
at
• Valid
Driver’s
Grace Medical Home. License or Photo ID
Proof of Identity
Living in Orange County
for at least two months
Earning less than
200% of the Federal
Poverty Line
(See Federal
Poverty Chart)
Uninsured and not
enrolled for government
assisted health care
programs (such as
Medicaid, Medicare
& VA benefits)
•
•
•
•
Social Security Card
Uninsured and not
Green Card enrolled for government
assisted health care
Birth Certificate
programs (such as
Medicaid, Medicare
Voter’s Registration
& VA benefits)
Card
$5,430
$6,122
$6,186
(Last 4 Weeks)
• Tax Return (1040)
• Most Recent Tax
Return or Letter
of Support
• Letter from Employer
Verifying Income
• College ID
(if Applicable)
Patient may be required
to sign a form verifying
they do not have
insurance.
407.936.2785 Ext. 2064
| Fax:
Poverty
Lin
6 3
(See Federa
7 4
Poverty Cha
8 5
$7,508
9 6
$8,202
• Pay Stubs
Living in Orange County
• Tax Return (1040)
•
Lease
or
Rental
(Last
4
Weeks)
10
for at least two months EXAMPLE: If you are a single parent caring for two 7
• Most Recent Tax
Contract
Federal
Poverty
Chart
children
and
you earn
less than $40,179 annually Uninsured
• Tax
Return
(1040)
Return or Letter
8
Earning less than
EXAMPLE
of Support
(or $3,348
a
month),
then
your family unit resides
enrolled for
•
Most
Recent
Tax
Number
in
200%
Poverty
200%
Poverty
200%
of
the
Federal
9
• Letter from Employer
below
200%
the
Level.
children
assisted an
he
• Return
Pay
Stubs
or Federal
Letter Poverty Monthly
Poverty
Line
your
Family
Annual
Verifying
Income
programs
(Last
4 Weeks)
10
of
Support
(or
$3,348
• College
Unit
Threshold
Threshold Medicaid,
(See ID Federal
Tax Return
(1040)
(if Applicable)
• • Letter
from Employer
below 200%
Poverty
Earning Chart)
less than
1 Federal
200% of the
Poverty Line
2
Patient may be required
to sign (See
a form
verifying
Federal
they do not have 3
Poverty
Chart)
insurance.
COST TO PATIENT
& VA bene
EXAMPLE
Income
$23,760
$1,980
• Verifying
Most
Recent
Tax
Grace
Medical
Home
is a non-profit
medical home.
children an
Return
or
• College
ID Letter
Volunteers
do most
of the work here, and generous
All patients und
$32,040
$2,670
of make
Support
Applicable)
donors (if
it possible for us to provide these (or
legal $3,348
guardian.
services.
Patients
a flat fee at $3,360
each visit (for below 200
• Letter
from pay
Employer
$40,320
Grace
Med
example,
$10) and
do not have to pay extra if the
Verifying
Income
Volunteers
$4,050
visit $48,600
includes
services
like
blood
tests,
X-rays,
• College
ID be required
Patient
may
patient (if education,
etc. There may be other costs
donors ma
Applicable)
to
sign
a
form
verifying $4,740
$56,880
if extra testing or specialty referrals
are needed
services. P
they
do
not
have
outside of Grace Medical Home. If you are
Grace Med
$65,160
$5,430
insurance.
$
experiencing financial hardship, we will work example,
Tel:
Volunteers
with
you.
Patient
may be required $6,122 visit include
$73,460
Uninsured 4 and not
enrolled for government
All patients under the age of 18 must be accompanied by a parent or
assisted health
5 care
legal guardian. Legal guardians must supply proof of guardianship.
programs (such as
• Utility Bill
Medicaid, 6 Medicare
Uninsured and not
& VA benefits)
enrolled for
• Lease or Rental
7 government
assisted health care
to sign a form verifying
Contract
All patients under the age of 18 must be accompanied by a parent or
$81,780
$6,186
programs 8 (such as
they do not have
legal guardian. Legal guardians must supply proof of guardianship.
Tel: 407.936.2785 Ext. 2064
| Fax: Medicare
407.936.2792 | insurance.
www.GraceMedicalHome.org
Medicaid,
9
$90,100
$7,508
& VA benefits)
• Pay Stubs
All patients under the age of 18 must be accompanied by a parent or
legal guardian. Legal guardians must supply proof of guardianship.
Tel:
Birth Certificate
6
Utility
Bill $65,160
ARE YOU AT • • • OR
Voter’s Registration
7
$73,460
• Lease or Rental
Card
8
$81,780
BELOW 200% THE
Contract
9
$90,100
• Pay Stubs
FEDERAL POVERTY
LINE?
• 10
Utility Bill $98,420
(Last 4 Weeks)
• Utility Bill
Living
in Orange County
• Lease
or Rental
Contract
for at least two months
COST T
COST T
40
donors ma
patient edu
services. P
if extra test
example, $
outside of G
visit include
experiencin
10
$98,420
$8,202
patient edu
All patients under the age of 18 must be accompanied by a parent or
with you.
legal guardian. Legal guardians must supply proof of guardianship.
if extra test
EXAMPLE: If you are a single parent caring for outside
two of
children
and you earn Ext.
less
than | Fax:
$40,179
annually
experiencin
Tel: 407.936.2785
2064
407.936.2792
| www
with you.
(or $3,348 a month), then your family unit resides
below 200% the Federal Poverty Level.
Tel: 407.936.2785 Ext. 2064 | Fax: 407.936.2792 | www
COST TO PATIENT
Grace Medical Home is a non-profit medical home.
Volunteers do most of the work here, and generous
donors make it possible for us to provide these
services. Patients pay a flat fee at each visit (for
example, $10) and do not have to pay extra if the
visit includes services like blood tests, X-rays,
patient education, etc. There may be other costs
if extra testing or specialty referrals are needed
outside of Grace Medical Home. If you are
experiencing financial hardship, we will work
with you.
407.936.2792 | www.GraceMedicalHome.org