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Eligibility depends on household income, family size, and required documentation such as proof of income for adults and current pay stubs. Applicants submit the completed confidential application and supporting materials in person or by fax, and receive a final eligibility determination within 14 calendar days. 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The program also depends on the required documentation being submitted.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What documents are required when applying?",{"text":114,"@type":110},"Applicants must provide proof of income for anyone 18+ in the household, including current pay stubs from the last 3 months. Other acceptable proof examples include W-2 statements, bank statements, last year’s tax return, or written statements from an employer.",{"name":116,"@type":107,"acceptedAnswer":117},"Where and how should the completed application be submitted?",{"text":118,"@type":110},"Return the documents in person to Jamestown Family Health Clinic or by fax to 360-582-4800. A final determination is provided within 14 calendar days after receiving a completed application with required documentation.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},280998,1790213149,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":40,"category_name":41,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":79,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":73},687207024643,"https://ap-avatar.wpscdn.com/davatar_3d24733baf745e90a7e4bdd5f77d97b2","Jamestown HealthCARE  \nFinancial Assistance  \nJamestown HealthCARE is committed to providing community-wide access to anyone in need. Our Financial Assistance module was created to eliminate financial constraints that would otherwise be a barrier to medically necessary care.  \nDepending on your household income and family size, you may be eligible for fee discounts. We have staff available to assist with completing your application, eligibility, and applying for medical insurance.  \nJamestown HealthCARE has expanded our fee schedule to exceed Federal Poverty Guidelines to better serve our patients.  \nOur Financial Assistance will apply to any medically necessary services provided by a  \nlicensed medical professional within Jamestown HealthCARE, depending on your eligibility.  \nHow to apply for Financial Assistance:  \nComplete the attached application.  \nObtain proof of income for anyone 18+ years old residing in your household. (Last 3 months)  \nCurrent pay stubs (Last 3 months)  \nReturn the documents noted above in person to Jamestown Family Health Clinic or by fax to 360-582-4800.  \nEligibility will be based on review of the application, family size, and income. We will notify you of the final determination within 14 calendar days of receiving a completed application accompanied by the required documentation.  \nWe want to help. Please submit your application promptly!  \nJamestown Family Health Clinic  \n808 N 5th Ave  \nSequim, WA 98382 Ph . 360-683-5900  \nFx . 360-582-4800 1  \n2024 Jamestown HealthCARE Medical Sliding Fee Scale  \n\n| Sliding Scale-Medical |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- |\n|  | Poverty Level | 0-150% | 151-200% | 201-250% | 251-300% |\n| Family Size | Income Level | 100% Discount | 75% Discount | 50% Discount | 25% Discount |\n| 1 | Annual (up to) Monthly | $22,590.00\u003Cbr>$1,882.50 | $30,120.00\u003Cbr>$2,510.00 | $37,650.00\u003Cbr>$3,137.50 | $45,180.00\u003Cbr>$3,765.00 |\n| 2 | Annual (up to) Monthly | $30,660.00\u003Cbr>$2,555.00 | $40,880.00\u003Cbr>$3,406.67 | $51,100.08\u003Cbr>$4,258.34 | $61,320.16\u003Cbr>$5,110.01 |\n| 3 | Annual (up to) Monthly | $38,730.00\u003Cbr>$3,227.50 | $51,640.00\u003Cbr>$4,303.33 | $64,549.92\u003Cbr>$5,379.16 | $77,459.84\u003Cbr>$6,454.98 |\n| 4 | Annual (up to) Monthly | $46,800.00\u003Cbr>$3,900.00 | $62,400.00\u003Cbr>$5,200.00 | $78,000.00\u003Cbr>$6,500.00 | $93,600.00\u003Cbr>$7,800.00 |\n| 5 | Annual (up to) Monthly | $54,870.00\u003Cbr>$4,572.50 | $73,160.00\u003Cbr>$6,096.67 | $91,450.08\u003Cbr>$7,620.84 | $109,740.16 $9,145.01 |\n| 6 | Annual (up to) Monthly | $62,940.00\u003Cbr>$5,245.00 | $83,920.00\u003Cbr>$6,993.33 | $104,899.92 $8,741.66 | $125,879.84\u003Cbr>$10,489.98 |\n| 7 | Annual (up to) Monthly | $71,010.00\u003Cbr>$5,917.50 | $94,680.00\u003Cbr>$7,890.00 | $118,350.00 $9,862.50 | $142,020.00\u003Cbr>$11,835.00 |\n\nJamestown HealthCARE  \nFinancial Assistance Application-Confidential  \n\n| Please fill out all information completely. If it does not apply, please check \"No\" or write NA. |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- |\n| PATIENT AND GUARANTOR INFORMATION |  |  |  |  |  |\n| First name: Middle name: Last name: |  |  |  |  |  |\n| Gender: □ Male □ Female □ Other |  | Date ofbirth: |  | Social Security No. |  |\n| Mailing address: |  |  |  | Phone number: |  |\n| Guarantor financially responsible: | Guarantor date ofbirth: |  | Guarantor Social Security No. |  | Guarantor relationship to patient: |\n| Employment status: □ Employed-hire date: □ Unemployed-as of date: □ Disabled □ Retired □ Other: |  |  |  |  |  |\n| SCREENING INFORMATION |  |  |  |  |  |\n| Do you need an interpreter? □ No □ Yes If yes, list preferred language: |  |  |  |  |  |\n| Does the patient currently have health insurance? □ No □ Yes |  |  |  |  |  |\n| Has the patient applied for WA state Medicaid? □ No □ Yes May be required before being consideredforfinancial assistance |  |  |  |  |  |\n| Is the patient eligible for Indian Health Services? □ No □ Yes If yes, list tribe: |  |  |  |  |  |\n| Is the patient currently homeless? □ No □ Yes |  |  |  |  |  |\n| FAMILY INFORMATION |  ","cbCait2GbWqGrvTS","https://ap.wps.com/l/cbCait2GbWqGrvTS","pdf",251209,"English","# Financial Assistance overview\n## Eligibility and discounts\n# How to apply\n## Application submission\n## Documentation requirements\n# 2024 Medical Sliding Fee Scale\n## Poverty level and family size discounts\n# Financial Assistance Application - Confidential\n## Patient and guarantor information\n## Screening and family information\n## Income and monthly expense information\n## Additional notes","[{\"question\":\"What factors determine eligibility for Jamestown HealthCARE Financial Assistance?\",\"answer\":\"Eligibility is based on review of the application, family size, and income. The program also depends on the required documentation being submitted.\"},{\"question\":\"What documents are required when applying?\",\"answer\":\"Applicants must provide proof of income for anyone 18+ in the household, including current pay stubs from the last 3 months. Other acceptable proof examples include W-2 statements, bank statements, last year’s tax return, or written statements from an employer.\"},{\"question\":\"Where and how should the completed application be submitted?\",\"answer\":\"Return the documents in person to Jamestown Family Health Clinic or by fax to 360-582-4800. A final determination is provided within 14 calendar days after receiving a completed application with required documentation.\"}]","Jamestown HealthCARE Financial Assistance Application - Confidential | PDF",1789563487]