SCHEDULE TODAY
To make an appointment, please use the intake forms below, call us at (215) 333-2600, or email us at shamsclinic@icnarelief.org. Our services have different hours of operations, so please read through the below information carefully. We look forward to serving you!
PRIVACY AND HIPAA
The SHAMS Clinic complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The SHAMS Clinic protects confidential health care information, known as “Protected Health Information” (PHI).
Below is a summary of your privacy rights under HIPAA.
The SHAMS Clinic legal duties and privacy practices regarding your PHI are also included in this Summary Notice.
The SHAMS Clinic may use and give your health information to:
- Treat you
- Operate health care services
The SHAMS 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 The SHAMS Clinic shared your PHI
- Ask The SHAMS Clinic to limit the information it shares
- Ask for a copy of your privacy notice
- Write a letter of complaint to The SHAMS 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, please contact The SHAMS Clinic at shamsclinic@icnarelief.org
ELIGIBILITY REQUIREMENTS
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
| 2020 POVERTY GUIDELINES FOR THE 48 CONTIGUOUS STATES AND THE DISTRICT OF COLUMBIA | |
|---|---|
| PERSONS IN FAMILY/HOUSEHOLD | POVERTY GUIDELINE |
| For families/households with more than 8 persons, add $4,480 for each additional person. | |
| 1 | $12,760 |
| 2 | $17,240 |
| 3 | $21,720 |
| 4 | $26,200 |
| 5 | $30,680 |
| 6 | $35,160 |
| 7 | $39,640 |
| 8 | $44,120 |
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
2. 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 copy of their most recent tax return.
- If patient is unemployed, then we need letter of support from whomever is supporting them. For example, information about the person who is feeding and giving shelter them. We need that information from the person him/herself. See attached letter of support form.
- Child support, Alimony, Food Stamps, SSI
3. Proof of address
- If your ID has your current address, you may upload a picture of it as your proof of address
- If your ID does not have your current address, you may upload a picture of a bill or document with YOUR name and address.
Requisitos de elegibilidad
- No tener seguro medico
- 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 completeada 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
2. 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
3.Prueba de domicilio:
Si su identificacion tiene su direcion puede ser usada como prueba de residencia.
Un bil reciente que tenga su nombre y direcion.