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It also collects household size and a list of each person living in the home, including income and benefits information.","Answer",{"name":65,"@type":60,"acceptedAnswer":66},"How is eligibility determined in the application?",{"text":67,"@type":63},"Eligibility is assessed using total household income, which includes employment income plus listed benefits. The form provides a maximum qualifying annual income table by family size, with the total household income not exceeding 200% of the Federal Poverty Rate.",{"name":69,"@type":60,"acceptedAnswer":70},"What documents are required when submitting the application?",{"text":71,"@type":63},"Submission requires proof of income (two months of most recent pay stubs, most recent W2, and award statements for additional income), proof of residency, and a valid photo ID copy. The form also notes that patients are seen by appointment only, after approval.","https://schema.org",{"og:url":32,"og:type":74,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":76,"canonical":32},"index,follow",{"doc_id":78,"site_id":7},286916,1789964236,{"code":4,"msg":81,"data":82},"success",[83,88,93,98,103,108,112,117,122],{"id":84,"doc_module":22,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},11,"Presentations",90,"presentations",{"id":89,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},12,"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":110,"slug":111},17,40,"forms",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},18,"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":81,"data":127},{"doc_id":78,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":109,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":30,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":26,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":139,"read_time":22},7971474921005,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","“In the same way, let your light shine before others, so that they may seeyour good works and give glory to your Father who is in heaven.”Matthew 5:16  \n5:16 Clinic, Inc .  \nChristian Medical/Dental Mission  \n810 E Mt Vernon St, Somerset, KY 42501 (606)-802-2069  \nAPPLICATION/VERIFICATION OF FINANCIAL INFORMATION  \nPatient’s Name   Date   Social Security \\#   Phone\\#  Email   Date of Birth   Home Address   Employer   Phone\\#  Address   Work Fulltime or Parttime?   How Many Hours per Week?   Annual Income $  Provide 2 months ’ pay stubs and most recent W2) Housing: (Rent/Own/Homeless) Marital Status: (Single/Married/Widowed/Divorced)  \nHow many people live in your home?   Please list each person living with you:  \nName   SS\\#  Name   SS\\#  Name   SS\\#  Name   SS\\#   \nDo you or any members of your household receive any of the following benefits? If so, please provide a copy of the award statements for each, and list the monthly amount received .  \n\n| Unemployment | $ | Worker’s Comp | $ |\n| --- | --- | --- | --- |\n| Social Security | $ | Disability | $ |\n| Child Support | $ | Kinship Care | $ |\n| State Supplemental | $ | Medical Assistance | $ |\n| Alimony | $ | SNAP | $ |\n\nAre other members of your household employed?   If so, please provide 2 months' pay stubs and their most recent W2. What is their total annual income? $   \nYour Total Household Income = All Employment Income + Benefits (listed above) What is your Total Household Income? $   \nDo you have Dental Insurance?   Do you have Medical Insurance?   Do you have Medicaid?   If so, please provide policy \\#  How can we help you? Please describe your dental/medical needs:   \n  Date    \nApplicant Signature  \nBy signing this application, I certify that the information contained in this form is true and correct to the best of my knowledge. I hereby grant permission for 5:16 Clinic and its agents to verify my employment, income, insurance coverage, Medicaid status and any other pertinent information needed to determine if I qualify for free dental and/or medical services.  \nIf you have questions about whether you and your family qualify, here is a check list:  \n  Do youlive inPulaski County ?  \n  Someone in your household is employed at least 32 hours per week   You DO NOT have Dental Insurance  \n  You're Uninsured or Underinsured for Medical Services  \n  You meet the income guidelines below – with total household income * not exceeding 200% of the Fedeal Poverty Rate?  \n*Note:Total Household Income includes all income from employment and all other sources received by applicant, spouse, domestic partner and all other persons living in your house.  \n\n| Qualifying Income by Family Size | Maximum\u003Cbr>Annual Income |\n| --- | --- |\n| One person | $29,160 |\n| Two people | $39,440 |\n| Three people | $49,720 |\n| Four people | $60,000 |\n| Five people | $70,280 |\n| Six people | $80,560 |\n| Seven people | $90,840 |\n| Eight people | $101,120 |\n| Nine people or more | $111,400 |\n\nPlease complete and submit online or mail your completed application to: 810 E. Mt. Vernon St, Somerset, KY 4250, along with:  \n1. Proof of income (2 months most recent pay stubs, most recent W2, and award statements for any additional income.)  \n2. Proof of residency (letter from landlord, utility bill, property tax bill, etc.)  \n3. Valid photo ID (copy)  \nNote* We are unable to provide acute or emergency care. Patients are seen by appointment only, after approval.  \n*Patient Non-Discrimination Policy: The 5:16 Clinic is committed to providing quality service to patients of all backgrounds. In accordance with this mission, the 5:16 Clinic does not exclude, deny service to, or otherwise discriminate against any person on the basis of age, sex, marital status, creed, race, color, national origin, or any other legally protected class or on the basis of disability or age in admission to, participation in or receipt of any of its services. *This statement is in accordance with the provisions of Title VI of the Civil Righ","cbCaio8OEyDVoUZT","https://ap.wps.com/l/cbCaio8OEyDVoUZT","pdf",863173,"English","# Application/Verification of Financial Information\n## Patient and Household Information\n## Benefits and Income Details\n## Insurance and Medicaid Questions\n## Submission Instructions and Required Documents\n## Certification, Authorization, and Non-Discrimination Policy","[{\"question\":\"What information does the 5:16 Clinic financial verification application require?\",\"answer\":\"It requests the patient’s name, contact details, date of birth, home address, employer and work status, hours per week, annual income, and insurance coverage details. It also collects household size and a list of each person living in the home, including income and benefits information.\"},{\"question\":\"How is eligibility determined in the application?\",\"answer\":\"Eligibility is assessed using total household income, which includes employment income plus listed benefits. The form provides a maximum qualifying annual income table by family size, with the total household income not exceeding 200% of the Federal Poverty Rate.\"},{\"question\":\"What documents are required when submitting the application?\",\"answer\":\"Submission requires proof of income (two months of most recent pay stubs, most recent W2, and award statements for additional income), proof of residency, and a valid photo ID copy. The form also notes that patients are seen by appointment only, after approval.\"}]","5:16 Clinic - Application/Verification of Financial Information 2023 | PDF",1789631686]