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ELIGIBILITY REQUIREMENTS:

ENGLISH:

You will have to complete the new patient clinic application located in “FORMS” 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 250% 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

Chart for AZ income guidelines:

Household sizeWeekly incomeMonthly incomeAnnual
1$260$1,040$12,490
2$352$1,409$16,910
3$444$1777$21,330
4$536$2,145$25,750
5$628$2,514$30,170
6$720$2,882$34,590
7$812$3,250$39,010
8$904$3,619$43,430
Each additional person$4,420

 

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

Our address is:

AZ Shifa Clinic

5030 S. Mill Ave. Suite C5

Tempe, AZ 85282-6834

If you have any questions, you can call: (480) 597-6029

Our fax number is: (480) 590-6864

SPANISH:

Tendrá que completar una solicitud para pacientes y cumplir con nuestros requisitos de elegibilidad antes de programar una cita con un médico. Todos los pacientes deben renovar la aplicación cada año.

Requisitos de elegibilidad:

  • No tener seguro médico
  • Tener un nivel de ingresos que se encuentre dentro del 250% nivel federal de pobreza según la cantidad de personas en su hogar.

Una vez que se haya completada su solicitud, se le programará una cita para que vea a un proveedor. Los pacientes deben volver a calificar cada año.

Documentos requeridos:

  1. Documentos de identificación (cualquiera de los siguientes):
  • Licencia de conducir
  • Tarjeta de identificación del DMV
  • Pasaporte Tarjeta verde válida
  1. Prueba de ingresos para cada miembro de su hogar:
  • Si el paciente está empleado, entonces necesitamos una copia de su talón de cheque (las últimas 4 semanas) o una carta del empleador.
  • Si el paciente trabaja por cuenta propia, necesitamos una copia de su declaración de impuestos más reciente.
  • Si el paciente está desempleado, entonces necesitamos una carta de apoyo de quien la esté apoyando. Por ejemplo, información sobre la persona que los alimenta y les da cobijo. Necesitamos esa información de la persona misma.
  • Manutención de los hijos, pensión alimenticia, estampillas de comida, SSI
  1. Prueba de domicilio:
  • Si su identificación tiene su dirección puede ser usada como prueba de residencia.
  • Un bil reciente que tenga su nombre y dirección.

Puede completar todas las solicitudes y cargar los documentos requeridos electrónicamente a través de nuestro formulario de sitio web seguro y compatible con HIPAA.

Nuestra dirección es:

AZ Shifa Clinic

5030 S. Mill Ave. Suite C5

Tempe, AZ 85282-6834

Si tiene alguna pregunta, no dude en llamarnos al: (480) 597-6029

Nuestro número de fax es: (480) 590-6864

 

PRIVACY POLICY AND HIPAA:

Summary HIPAA Notice of Privacy Practices:

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

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

Summary of Your Privacy Rights:

AZ Shifa Clinic may use and give your health information to:

  • Treat you
  • Operate health care services

AZ 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 AZ Shifa Clinic shared your “Protected Health Information” (PHI)
  • Ask AZ Shifa Clinic to limit the information it shares
  • Ask for a copy of your privacy notice
  • Write a letter of complaint to AZ 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.

PATIENT RESOURCES:

  • 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)