Community Care Clinic of Rowan County, Inc.
Application Instructions for Services
If you are eligible for subsidy through the Affordable Healthcare Act (make between 100400% of Federal Poverty level) or can be covered under a spouse’s insurance, you must do
so. We will only continue treating patients that are unable to obtain insurance coverage.
1.
Complete the Request for Services Form and Enrollment Form. If you are self employed, you must
also complete the Self-employed Statement of Income. These forms can be returned at any time the
clinic is open. Incomplete application forms for service may cause a delay in services. This
instruction for services explains the items to bring to the Enrollment Clinic for verification of
eligibility.
2.
The application for services will be reviewed by the clinic staff. Please be sure that you have given a
phone number at which you can be contacted. You should expect to hear from the clinic within 14
business days of completing your application. If you are approved, you will be given a date and time
to attend the Enrollment Clinic.
3.
The following information must be brought to the Enrollment Clinic in order to be scheduled for an
appointment. During the Enrollment Clinic, copies of the information below will be made and you
will complete any other forms needed for your chart. If all information is not presented, you can
not be scheduled for an appointment and will have to bring missing information to the next
scheduled Enrollment Clinic.
Proof of income for patient Current pay stubs, verification from ESC for unemployment, monthly pension
statement, letter from social security showing monthly benefit for retirement or SSI for dependent, child
support, etc. Bank statement showing direct deposit cannot be used for proof of income. If you do not
have any income, you will have to fill out a Zero Income Form during the Enrollment Clinic. If you are
applying for disability, we will need a letter of verification of claim from the Social Security Administration or
letter from your lawyer, if you have one.
Proof of income for other household members
This is current pay stubs, verification from ESC for
unemployment, monthly pension statement, letter from social security showing monthly benefit for retirement
or SSI for dependent, child support, etc. Bank statement showing direct deposit cannot be used for proof of
income.
Income tax return If you filed taxes for the most recent tax year, we need either a copy of the 1040, or a
transcript of you return. A transcript can be requested by calling 1-800-908-9946 or on-line at IRS.gov. If
no taxes were filed, we must have verification of non-filing. This may also be requested on-line at IRS.GOV
or by submitting a 4506-T form. The clinic can submit the form on your behalf, and the letter will be mailed
directly to us.
Proof of Identification You will need a valid North Carolina driver’s license or state identification card with a
Rowan County address. You will also need to bring your social security card or a letter from the Social
Security Administration with verified social security number.
Medicaid denial OR written statement from Social Services (Letter of Inquiry) stating you are not eligible for
Medicaid less than 6 months old. If Social Services denies your Medicaid because you have not given
them the information they requested, you must go back and complete the application before eligibility
can be approved. If you have applied for Medicaid, but have not received an answer, we need proof of an
application. We have included a letter that you can take with you to Social Services to apply for Medicaid.
Please take this letter with you to the Department of Social Services in case there are questions regarding the
paperwork you are requesting.
To Whom It May Concern:
On order to provide medications at no cost to clients at the Community Care Clinic, various drug companies
require documentation that the client has either applied for, OR is not eligible for Medicaid. A letter of inquiry
is acceptable if it states the client does not meet guidelines to receive Medicaid benefits. We do encourage
clients to apply only if they feel they may be eligible for benefits. If the client does apply for benefits and is
denied, we need a copy of the denial letter within 90 days of the initial visit to the clinic.
If you need any further information, or have questions regarding required documentation, please feel free to
contact me at 704-636-4523.
Sincerely,
Vicki Peeler CPht
Prescription Assistance Coordinator
COMMUNITY CARE CLINIC OF ROWAN COUNTY
ENROLLMENT FORM/REQUEST FOR SERVICES
Date: ______/______/______ Sex:  M  F
Race: _________ Age: ______
Birth date: ______/______/_________
Marital Status:  Married  Single  Separated  Divorced  Widowed  Living with significant other
Name: _________________________________________________________________ SS# _______-_______-__________
Last
First
Middle
Are you a US citizen  Yes  No
Maiden
Are you a legal resident  Yes  No Rowan County Resident  yes  no
Do you speak English? Yes  No If no, can you provide a translator who is not a family member? Yes No
Street Address: ______________________________________City______________________________ Zip _____________
Mailing Address: ____________________________________City_______________________________ Zip ____________
Best phone number to reach you_________________________________
Next of Kin / Emergency Contact Name ______________________________________ Relationship ____________________
Contact phone #____________________________________________
How did you hear about the clinic?_________________________________________________________________________
Did you file taxes?  Yes  No
Are you claimed as a dependent on someone else’s taxes? Yes  No
Are you filing for Disability? ___Yes ___ No
Do you have any of the following?
Medicaid  Yes  No
Medicare  Yes  No
Medical insurance Yes  No
Dental insurance  Yes  No
Are you eligible for VA benefits?
Medical Yes  No
Dental  Yes  No
Prescription  Yes  No
LIST TOTAL MONTHLY HOUSEHOLD INCOME AMOUNTS
Salary/wages ______________
Disability________________
Social Security_____________
Worker’s Comp___________
Unemployment_____________
Self employment___________
Pension____________
Other____________________
Number of adults in household_______ Number of Children in household______
SERVICES REQUESTED
______I need to see a doctor at this clinic (See back) OR
______I wish to keep my own physician, and need assistance
with medications only
______I need to see the dentist. Reason for needing to see a dentist
 Toothache
 Cavities
Extraction
Office Use Only
ID ____
SS Card___
Income____
Taxes_____
Disability App___
Medicaid
denial/App______
ACA________
 Broken tooth
other (Please explain)____________________________________________________________
_____If applying for medical and dental services,what is your immediate need? Medical or Dental (circle ONE)
NOTE: The Community Care Clinic does not do pain management or provide surgical services. If you need
treatment for depression or mental health issues, contact Daymark at 704-633-3616. We do not prescribe
narcotics or controlled drugs. If these issues are your reason for wanting to be seen, it is highly unlikely that
the Community Care Clinic will be able to serve you.
__________________________________________________________________________________________
Applicant Signature
Date
Community Care Clinic of Rowan County
Patient Health History Form
Your Name:___________________________________________ Date: ___________________
(Please Print)
Reason for needing to see a medical doctor
eading ________
__________________________________________________________________________________________
__________________________________________________________________
If you have your own doctor, and only need prescription assistance, what is your
Physician’s name and phone number?_______________________________________________
Are you allergic to any medications that you know of? _________________________________
What medications are you taking now, or should be taking on a regular basis?
1. ______________________________________
3. ______________________________________
5. ______________________________________
2. ______________________________
4. ______________________________
6. ______________________________
Are you currently being treated for depression or any other mental disorder? Yes ____No ____
Do you have any food allergies? ___________________________________________________
Do you have vision problems? Yes ____
No ____
When did you last have an eye exam and what doctor? _________________________________
Other health conditions (Check all that apply):
___Angina
___Anemia
___Arthritis
___Bladder infections
___Blindness
___Bronchitis
___Cataracts
___Cirrhosis of the liver
___Kidney infections/stones
___Seizures
___Emphysema
___Headaches
___Hearing Loss
___Hepatitis (Liver dis.)
___Strokes
___Tuberculosis
___Ulcers
__Other (please list)
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________________________________________________________________
Applicant Signature
Date