CHECKLIST

Please plan to arrive at Chris McNair Health Center, Western Health Center, or Pratt City Primary Care clinic, 30 minutes before your scheduled appointment to complete registration.

The following information will need to be provided to complete registration for enrollment in the HealthPlus+ Program:

Identification

Proof of Identification includes:

·         Valid Alabama Driver’s License

·         Valid Alabama Identification Card

·         Military Identification

Social Security Number

Proof of Social Security Number includes:

·         Social Security Card

·         Driver’s License

·         Pay check stub

·         Income tax return

Residency

Proof of residency includes:

·         Utility bills addressed to patient’s current address

·         Veteran’s Administration, Social Security or Aid to Dependent Children award letter

·         Current Lease/rental agreement

·         Complete Referral Form/Verification of Residency/Income (JCDH-OHCS-420-000) for participants in the Birmingham Healthcare Program.

Income  

Proof of Income includes:

·         Current check stub

·         Earned income credit (EIC)

·         Net earnings from self-employment

·         Business profits

·         Alimony or child support

·         Sick pay, workmen’s compensation, vacation pay

·         Unemployment Compensation

·         Social Security cash benefits, VA benefits, Black Lung benefit, pensions/retirement, annuities

·         Cash contributions from relatives and nonrelatives

·         Net investment income (rent, interest, dividends, annuities, etc.)

·         New royalties and any other cash income including received/withdrawn from savings, investments, trusts, estates, or other resources

·         Lump sum payments (gifts, inheritances, lottery winnings, severance pay)

·         Pension or retirement payment(s)