Patient Intake (this will be an IntakeQ form)


You will have to complete the new patient application (attached below) and meet our eligibility requirements prior to scheduling an appointment with a doctor.

Eligibility Requirements, you must:

  • Have no health insurance
  • Have an income level that falls within 200% of the Federal Poverty Level based on the number of people in your household.

After eligibility requirements have been met, you will be scheduled to see a provider. Patients must re-qualify every year.

Required Documents:

  1. Identification Documents, any one of the following:
  • Driver’s license
  • DMV ID card
  • Passport
  • Valid Green Card
  1. Proof of Income for each working member of your household. Choose documents as applicable:
  • If patient is employed, then we need a copy of their paycheck stub (last 4 weeks) or letter from employer.
  • If patient is self employed, then we need a copy of their most recent tax return.
  • If patient is unemployed, then we need a signed letter of support from whomever is supporting them.  For example, information about the person who is feeding and giving them shelter. We need that information from the person himself/herself. See attached Letter of Support Form.
  • Child support, Alimony, Food Stamps, SSI

You can complete all applications and upload required documents electronically through our HIPAA compliant and secure website form submission.

If you have any questions, you can email or fax.


Summary HIPAA Notice of Privacy Practices:

Shifa Clinic complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  Shifa Clinic protects confidential health care information, known as “Protected Health Information” (PHI).  Below is a summary of your privacy rights under HIPAA.

Shifa Clinic legal duties and privacy practices regarding your PHI are also included in this Summary Notice.

Summary of Your Privacy Rights:

Shifa Clinic may use and give your health information to:

  • Treat you
  • Operate health care services

Shifa Clinic may use and give your health information for:

  • Law enforcement requests
  • Judicial and administrative proceedings related to legal actions
  • Healthcare fraud and abuse detection or compliance with the law
  • Use by another healthcare provider treating you
  • Government health oversight activities
  • Reports required by law related to births, deaths or diseases:
  • Reports required by law related to neglect and abuse, or domestic violence
  • Notifying a party about exposure to a possible communicable disease
  • Military, national defense, and security or other governmental functions
  • Workers’ compensation purposes and in compliance with related laws
  • Averting a serious threat to public health and safety

You have the right to:

  • Inspect or get a copy of your medical record
  • Change information on your medical record if you think it is incorrect
  • Get a list of persons whom Shifa Clinic shared your “Protected Health Information” (PHI)
  • Ask Shifa Clinic to limit the information it shares
  • Ask for a copy of your privacy notice
  • Write a letter of complaint to Shifa Clinic or the federal government

If you have any questions or if you wish to file a complaint, or exercise any rights listed in this Summary or the complete Notice, please contact the office manager.


  • No Income exchange form – (this will be a link to an IntakeQ form)
  • Employer Declaration of Income – (this will be a link to an IntakeQ form)
  • Self Declaration of Income – (this will be a link to an IntakeQ form)