Program Application - Health Care Access

Have you applied to other programs for dental/vision/prescription assistance?*
- Yes
- No
If yes, what was the outcome?*
Please provide a brief summary as to the nature of your dental/vision/medication needs*
How did you learn about this program?*
Are you currently receiving services or have you received services from CHDC (Community Health & Dental Care) in Pottstown?*
- Yes
- No
If so, when?*
I understand and agree to the following Health Care Access Program (HCA) ZERO TOLERANCE NO SHOW POLICY: If I’m unable to keep a scheduled appointment at the provider’s office, I agree to call the provider office 48 hours in advance. Failure to do so will be considered a NO SHOW. Cancelling the same day is a NO SHOW. If I fail to contact the office, I will be responsible for a $50.00 NO SHOW FEE that must be paid to the provider prior to scheduling any further appointments. If I have a second NO SHOW, in addition to paying the $50.00 NO SHOW fee to the provider, I will have to wait 6 months to reapply to HCA for assistance. A third NO SHOW and I will no longer be eligible for the Health Care Access Programs. Any exceptions/emergencies will need to be discussed with HCA staff.
Consent*
I have read and understand the No Show Policy
I acknowledge that all of the information provided is true. I acknowledge that no other adult contributes to the income of the household. I understand that this application is for immediate care or emergency care and does not constitute ongoing financial support or care on part of the program or the doctor. The final approval is subject to a provider treatment request, available program funds, and program approval. (Approval is based upon the provider’s exam and program application verification and available funding. The Health Care Access Program does not guarantee approval for dental/vision/prescription/immigration services.) I agree to pay an administrative fee based upon my family income and Program financial guidelines. This fee will be agreed upon by the Program Administrator and myself and paid prior to any dental/vision visits. These fees are paid directly to the provider. I hereby authorize the release of any information regarding my medical condition and financial need by the Health Care Access Programs, its employees, affiliates and agents for the purpose of rendering services to myself or for whom I am making such authorization. I also acknowledge that the information provided to Health Care Access is true and correct to the best of my knowledge.
Consent*
I agree to these policies
Signature

In applying for funds under the Health Care Access Programs, I understand that all diagnosis of treatment and services rendered are the sole responsibility at the provider and his/her practice. I acknowledge that the program is designed to assist me by providing funding for said services subject to program approval. I understand that this program does not provide the ongoing services beyond what is approved at the time of my application. In the event that I need financial assistance for dental/vision/prescription services in the future, I must reapply to the program. Previous approval does not assure or guarantee a future approval of a new application. I agree to pay any required administrative co-payments established prior to my approval. All co-pays are to be submitted to the provider at my approved visits. I understand that the goal of the Health Care Access Programs is to enhance access to dental/vision care and prescription medications for Phoenixville area residents. Theis goal does not guarantee access or ongoing access to the provider of my choice not the right to see the same program provider if I receive a future application approval. Of course, a patient may continue as a private patient with any practitioner as mutually agreed upon by both provider and family. The provider who renders treatment to me should not charge me a fee for any service approved by the program. I may agree to additional services for a fee established by the provider. I reserve the right to become a private patient in the practice depending upon the provider’s availability. At no time does the Health Care Access Programs guarantee acceptance of approval of an application.
Consent*
I have read this Patient Disclaimer.
I have read this Patient Disclaimer.
Signature
Date
MM slash DD slash YYYY

It is the policy of Health Care Access Program that services will be provided to all individuals who are eligible without discrimination on the basis of HIV infection, race, creed, color, age, sex, gender, sexual orientation, religion, ancestry, national origin, physical or mental handicap (including substance abuse), immigrant status, political affiliation or belief. It is the policy of Health Care Access Program to provide all clients and those seeking services with a copy of the Client Grievance Policy and Procedures upon request and an opportunity to file a grievance. If you choose to file a grievance, you are assured that no adverse repercussions will occur to you in any future interaction with Health Care Access Program. A grievance may be filed for the following reasons: 1. You feel that you were improperly denied services. 2. You feel that the services were not effective. If you have a grievance or recommendation, you should first discuss it with the Program staff person you are working with. If this is not successful or if you feel this is not an option, you should proceed with the following steps: 1. A written statement should be prepared 9including date and time of grievance). You may ask for assistance from any staff. Use the Grievance Reporting form available from Executive Director. 2. Submit the grievance to the Program Director within 5 working days. An appointment will be scheduled for you to meet with the Executive Director to resolve your grievance. 3. If a resolution has not occurred within 10 working days, your grievance will be referred to the Board Chair. 4. If the determination of the Board Chair is still not satisfactory to you, it may be requested that the Health Care Access Board of Directors review the matter at their discretion, and their decision will be final.
Consent*
I have read this Grievance Policy & Procedure.
I have read this Grievance Policy & Procedure.
Signature
Date
MM slash DD slash YYYY

Step 1 of 7

Names of those making application that need help

Additional Persons

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