BECOME A

SHIFA PATIENT

 

SHIFA FREE CLINIC ELIGIBILITY REQUIREMENTS

To be eligible for Shifa Free Clinic services, you must:

· Have no health insurance

· Have a total household income not exceeding 250% of the Federal Poverty Level

· Submit the Required Documents found below:

1: IDENTIFICATION DOCUMENTS

2: PROOF OF INCOME

3: PROOF OF ADDRESS

Can be any of the following:

  • Driver’s License
  • DMV ID Card
  • Passport
  • Valid Green Card
  • Other forms of identification on a case by case basis
  • Employed:
  • Self-Employed:
  • Unemployed:
    • No Income Form
    • Letter of support from benefactor.
      • (I.E, Whomever is supporting the applicant and providing food & shelter. The identified person who is meeting basic needs is the one who must submit the Letter of Support on behalf of the patient applicant.)
  • Any Additional Income:
    • Child Support
    • Alimony
    • Food Stamps
    • SSI

Can be any of the following:

  • Current Driver’s License (if address is the same)
  • Any utility bill under the patient’s name
  • A letter of attestation from an approved agency representative

CONTINUE TO SHIFA APPLICATION:

ADULT APPLICATION
CHILD APPLICATION
APLICACION PARA ADULTOS
APLICACION PARA NIÑOS

PRIVACY POLICY & HIPPA

Summary of HIPAA Notice of Privacy Practices

Shifa Free Clinic complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Shifa Free Clinic protects confidential health care information, known as “Protected Health Information” (PHI). Below is a summary of your privacy rights under HIPAA. Shifa Free Clinic legal duties and privacy practices regarding your PHI are also included in this Summary Notice.

Summary of Your Privacy Rights

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

  • Treat you
  • Operate health care services

Shifa Free 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 with whom Shifa Free Clinic has shared your PHI
  • Ask Shifa Free Clinic to limit the information it shares
  • Ask for a copy of your privacy notice
  • Write a letter of complaint to Shifa Free Clinic or the federal government

If you have any questions, wish to file a complaint, or exercise any rights listed in this Summary or the complete Notice, please contact Shifa Free Clinic at shifa.sc@icnarelief.org