{"id":12488,"date":"2021-03-06T00:26:49","date_gmt":"2021-03-06T00:26:49","guid":{"rendered":"https:\/\/www.icnarelief.org\/shifaclinics\/?page_id=12488"},"modified":"2026-07-28T18:54:16","modified_gmt":"2026-07-28T18:54:16","slug":"patient-applications","status":"publish","type":"page","link":"https:\/\/www.icnarelief.org\/shifaclinics\/patient-applications\/","title":{"rendered":"Patient Applications"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; background_image=&#8221;https:\/\/www.icnarelief.org\/shifaclinics\/wp-content\/uploads\/sites\/2\/2026\/03\/Shifa-Webpage-Banner-1200-x-600-px-3.png&#8221; background_size=&#8221;stretch&#8221; width=&#8221;100%&#8221; max_width=&#8221;2560px&#8221; background_color_tablet=&#8221;#055205&#8243; background_last_edited=&#8221;on|desktop&#8221; background_enable_color_tablet=&#8221;on&#8221; background_enable_image_tablet=&#8221;off&#8221; background_size_tablet=&#8221;contain&#8221; background_size_phone=&#8221;contain&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; pac_dcm_carousel_specific_module_num=&#8221;0&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_text content_tablet=&#8221;<\/p>\n<\/p>\n<\/p>\n<p>BECOME A<\/p>\n<p>SHIFA PATIENT<\/p>\n<p>&#8221; content_phone=&#8221;<\/p>\n<p>BECOME A<\/p>\n<p>SHIFA PATIENT<\/p>\n<p>&#8221; content_last_edited=&#8221;on|phone&#8221; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; text_font=&#8221;Poppins|800|||||||&#8221; text_text_color=&#8221;#FFFFFF&#8221; text_font_size=&#8221;76px&#8221; custom_margin=&#8221;|||219px|false|false&#8221; custom_margin_tablet=&#8221;65px|||42px|false|false&#8221; custom_margin_phone=&#8221;0px|||0px|false|false&#8221; custom_margin_last_edited=&#8221;on|phone&#8221; custom_padding=&#8221;|21px||21px|false|true&#8221; text_font_size_tablet=&#8221;76px&#8221; text_font_size_phone=&#8221;33px&#8221; text_font_size_last_edited=&#8221;on|phone&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p style=\"padding-left: 40px\">BECOME A<\/p>\n<p style=\"padding-left: 40px\">SHIFA PATIENT<\/p>\n<p>&nbsp;<\/p>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][et_pb_row _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; pac_dcm_carousel_specific_module_num=&#8221;0&#8243; global_colors_info=&#8221;{}&#8221;][df_adh_heading _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][\/df_adh_heading][et_pb_text content_tablet=&#8221;<\/p>\n<\/p>\n<p>SHIFA FREE CLINIC ELIGIBILITY REQUIREMENTS<\/p>\n<p>&#8221; content_phone=&#8221;<\/p>\n<p>SHIFA FREE CLINIC ELIGIBILITY REQUIREMENTS<\/p>\n<p>&#8221; content_last_edited=&#8221;on|phone&#8221; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; text_font=&#8221;|600|||||||&#8221; text_text_color=&#8221;#000000&#8243; text_font_size=&#8221;40px&#8221; text_orientation=&#8221;center&#8221; text_font_size_tablet=&#8221;40px&#8221; text_font_size_phone=&#8221;26px&#8221; text_font_size_last_edited=&#8221;on|phone&#8221; text_line_height_tablet=&#8221;1.8em&#8221; text_line_height_phone=&#8221;1.8em&#8221; text_line_height_last_edited=&#8221;on|tablet&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p>SHIFA FREE CLINIC ELIGIBILITY REQUIREMENTS<\/p>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; width=&#8221;66%&#8221; width_tablet=&#8221;66%&#8221; width_phone=&#8221;100%&#8221; width_last_edited=&#8221;on|tablet&#8221; module_alignment=&#8221;center&#8221; border_width_all=&#8221;4px&#8221; border_color_all=&#8221;#F28D1D&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; width=&#8221;100%&#8221; max_width=&#8221;2560px&#8221; border_color_all=&#8221;#F28D1D&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; pac_dcm_carousel_specific_module_num=&#8221;0&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_text content_tablet=&#8221;&#8221; content_phone=&#8221;&#8221; content_last_edited=&#8221;on|tablet&#8221; module_id=&#8221;https:\/\/fplcalculator.com\/&#8221; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; text_font_size=&#8221;26px&#8221; text_line_height=&#8221;1.8em&#8221; custom_padding=&#8221;|35px||35px|false|true&#8221; text_font_size_tablet=&#8221;26px&#8221; text_font_size_phone=&#8221;18px&#8221; text_font_size_last_edited=&#8221;on|phone&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p style=\"padding-left: 40px\">To be eligible for Shifa Free Clinic services, you must:<\/p>\n<p style=\"padding-left: 80px\">\u00b7 Have <strong>no<\/strong> health insurance<\/p>\n<p style=\"padding-left: 80px\">\u00b7 Have a total household income<strong> not exceeding<\/strong> 250% of the <a href=\"https:\/\/fplcalculator.com\/\">Federal Poverty Level<\/a><\/p>\n<p style=\"padding-left: 80px\">\u00b7 Submit the Required Documents found below:<\/p>\n<p>[\/et_pb_text][difl_advancedtab content_container_bgcolor=&#8221;RGBA(255,255,255,0)&#8221; nav_container_bgcolor=&#8221;#009A50&#8243; use_sticky_nav=&#8221;off&#8221; nav_item_bgcolor=&#8221;#009A50&#8243; nav_item_active_bgcolor=&#8221;#F28D1D&#8221; _builder_version=&#8221;4.27.6&#8243; _module_preset=&#8221;default&#8221; title_active_text_color=&#8221;#FFFFFF&#8221; custom_padding=&#8221;|57px||57px|false|true&#8221; hover_enabled=&#8221;0&#8243; border_width_all_content_wrapper=&#8221;4px&#8221; border_color_all_content_wrapper=&#8221;#F28D1D&#8221; border_radii_nav_wrapper=&#8221;on|5px|5px|5px|5px&#8221; border_width_all_nav_wrapper=&#8221;4px&#8221; border_color_all_nav_wrapper=&#8221;#009A50&#8243; global_colors_info=&#8221;{}&#8221; content_padding__hover_enabled=&#8221;on|desktop&#8221; sticky_enabled=&#8221;0&#8243;][difl_advancedtabitem title=&#8221;1: IDENTIFICATION DOCUMENTS&#8221; navigation_link=&#8221;https:\/\/www.icnarelief.org\/shifaclinics\/patient-applications\/#difl_advancedtabitem_0&#8243; at_button_button_url_new_window=&#8221;1&#8243; content_padding=&#8221;|||25px|false|false&#8221; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; title_font=&#8221;|600|||||||&#8221; title_text_color=&#8221;#FFFFFF&#8221; title_font_size=&#8221;26px&#8221; text_font=&#8221;|600|||||||&#8221; text_text_align=&#8221;left&#8221; text_text_color=&#8221;#000000&#8243; text_font_size=&#8221;18px&#8221; header_text_color=&#8221;#000000&#8243; border_radii_textarea_border=&#8221;on|5px|5px|5px|5px&#8221; border_color_all_textarea_border=&#8221;#009A50&#8243; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p>Can be any of the following:<\/p>\n<ul>\n<li>Driver\u2019s License<\/li>\n<li>DMV ID Card<\/li>\n<li>Passport<\/li>\n<li>Valid Green Card<\/li>\n<li>Other forms of identification on a case by case basis<\/li>\n<\/ul>\n<p>[\/difl_advancedtabitem][difl_advancedtabitem title=&#8221;2: PROOF OF INCOME&#8221; navigation_link=&#8221;https:\/\/www.icnarelief.org\/shifaclinics\/patient-applications\/#difl_advancedtabitem_1&#8243; at_button_button_url_new_window=&#8221;1&#8243; content_padding=&#8221;|||25px|false|false&#8221; _builder_version=&#8221;4.27.6&#8243; _module_preset=&#8221;default&#8221; title_font=&#8221;|600|||||||&#8221; title_text_color=&#8221;#FFFFFF&#8221; title_font_size=&#8221;26px&#8221; text_font=&#8221;|600|||||||&#8221; text_text_align=&#8221;left&#8221; text_text_color=&#8221;#000000&#8243; text_font_size=&#8221;18px&#8221; header_text_color=&#8221;#000000&#8243; hover_enabled=&#8221;0&#8243; border_radii_textarea_border=&#8221;on|5px|5px|5px|5px&#8221; border_color_all_textarea_border=&#8221;#009A50&#8243; global_colors_info=&#8221;{}&#8221; sticky_enabled=&#8221;0&#8243;]<\/p>\n<ul>\n<li><strong>Employed:<\/strong>\n<ul>\n<li>Paystubs (last 60 days)\n<ul>\n<li>Weekly Pay: 4 Consecutive Paystubs<\/li>\n<li>Biweekly Pay: 2 Consecutive Paystubs<\/li>\n<\/ul>\n<\/li>\n<li>If paid in Cash, use:\n<ul>\n<li><a href=\"https:\/\/na4.documents.adobe.com\/public\/esignWidget?wid=CBFCIBAA3AAABLblqZhD8Zc9PqELPBc1_t6-3yU6fePAB6JD8hw7ep2BAHM7fQXhkj5HbZ8pSHeGGgOvnlFA*\">Cash Form: English<\/a><\/li>\n<li><a href=\"https:\/\/na4.documents.adobe.com\/public\/esignWidget?wid=CBFCIBAA3AAABLblqZhAEipA3PVYLxLpAp8Hwo_tfMPXSkKHZGOAW68-hjq29gNrvicPruLvX6gX5sckT_bs*\">Cash Form: Spanish<\/a><\/li>\n<\/ul>\n<\/li>\n<li>Typed Employer Letter<\/li>\n<\/ul>\n<\/li>\n<li><strong>Self-Employed:<\/strong>\n<ul>\n<li>Previous Year Tax Return<\/li>\n<\/ul>\n<\/li>\n<li><strong>Unemployed:<\/strong>\n<ul>\n<li>Typed letter of support from benefactor handsigned and notarized\n<ul>\n<li>(I.E, If someone helps pay for or provides the applicant&#8217;s food and housing, that person must complete and sign a letter of support for the applicant.)<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<li><strong>Any Additional Income:<\/strong>\n<ul>\n<li>Child Support<\/li>\n<li>Alimony<\/li>\n<li>Food Stamps<\/li>\n<li>Social Security<\/li>\n<li>Unemployment<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>[\/difl_advancedtabitem][difl_advancedtabitem title=&#8221;3: PROOF OF ADDRESS&#8221; navigation_link=&#8221;https:\/\/www.icnarelief.org\/shifaclinics\/patient-applications\/#difl_advancedtabitem_2&#8243; at_button_button_url_new_window=&#8221;1&#8243; content_padding=&#8221;|||25px|false|false&#8221; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; title_font=&#8221;|600|||||||&#8221; title_text_color=&#8221;#FFFFFF&#8221; title_font_size=&#8221;26px&#8221; text_font=&#8221;|600|||||||&#8221; text_text_align=&#8221;left&#8221; text_text_color=&#8221;#000000&#8243; text_font_size=&#8221;18px&#8221; header_text_color=&#8221;#000000&#8243; border_radii_textarea_border=&#8221;on|5px|5px|5px|5px&#8221; border_color_all_textarea_border=&#8221;#009A50&#8243; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p>Can be any of the following:<\/p>\n<ul>\n<li>Current Driver\u2019s License (if address is the same)<\/li>\n<li>Any utility bill under the patient\u2019s name<\/li>\n<li>A letter of attestation from an approved agency representative<\/li>\n<\/ul>\n<p>[\/difl_advancedtabitem][\/difl_advancedtab][et_pb_text _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; text_font_size=&#8221;26px&#8221; text_line_height=&#8221;1.8em&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p style=\"text-align: center\"><strong>CONTINUE TO SHIFA APPLICATION:<\/strong><\/p>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][et_pb_row column_structure=&#8221;1_2,1_2&#8243; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; module_alignment=&#8221;center&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;1_2&#8243; _builder_version=&#8221;4.20.2&#8243; _module_preset=&#8221;default&#8221; pac_dcm_carousel_specific_module_num=&#8221;0&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_button button_url=&#8221;https:\/\/intakeq.com\/new\/pr96w8&#8243; button_text=&#8221;   ADULT APPLICATION: ENGLISH&#8221; button_alignment=&#8221;center&#8221; _builder_version=&#8221;4.27.6&#8243; _module_preset=&#8221;default&#8221; custom_button=&#8221;on&#8221; button_text_size=&#8221;26px&#8221; button_border_width=&#8221;4px&#8221; button_border_color=&#8221;#283655&#8243; button_border_radius=&#8221;5px&#8221; button_icon=&#8221;&#x41;||divi||400&#8243; button_icon_color=&#8221;#F28D1D&#8221; hover_enabled=&#8221;0&#8243; button_text_size_tablet=&#8221;26px&#8221; button_text_size_phone=&#8221;18px&#8221; button_text_size_last_edited=&#8221;on|phone&#8221; global_colors_info=&#8221;{}&#8221; sticky_enabled=&#8221;0&#8243;][\/et_pb_button][et_pb_button button_url=&#8221;https:\/\/intakeq.com\/new\/is8oyq&#8221; url_new_window=&#8221;on&#8221; button_text=&#8221;CHILD APPLICATION&#8221; button_alignment=&#8221;center&#8221; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; custom_button=&#8221;on&#8221; button_text_size=&#8221;26px&#8221; button_border_width=&#8221;4px&#8221; button_border_color=&#8221;#283655&#8243; button_border_radius=&#8221;5px&#8221; button_icon=&#8221;&#x41;||divi||400&#8243; button_icon_color=&#8221;#F28D1D&#8221; custom_padding=&#8221;|30px||30px|false|true&#8221; button_text_size_tablet=&#8221;26px&#8221; button_text_size_phone=&#8221;18px&#8221; button_text_size_last_edited=&#8221;on|phone&#8221; global_colors_info=&#8221;{}&#8221;][\/et_pb_button][\/et_pb_column][et_pb_column type=&#8221;1_2&#8243; _builder_version=&#8221;4.20.2&#8243; _module_preset=&#8221;default&#8221; pac_dcm_carousel_specific_module_num=&#8221;0&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_button button_url=&#8221;https:\/\/intakeq.com\/new\/1jvhmt&#8221; button_text=&#8221;APLICACION PARA ADULTOS: SPANISH&#8221; button_alignment=&#8221;center&#8221; _builder_version=&#8221;4.27.6&#8243; _module_preset=&#8221;default&#8221; custom_button=&#8221;on&#8221; button_text_size=&#8221;26px&#8221; button_border_width=&#8221;4px&#8221; button_border_color=&#8221;#283655&#8243; button_border_radius=&#8221;5px&#8221; button_icon=&#8221;&#x41;||divi||400&#8243; button_icon_color=&#8221;#F28D1D&#8221; hover_enabled=&#8221;0&#8243; button_text_size_tablet=&#8221;26px&#8221; button_text_size_phone=&#8221;18px&#8221; button_text_size_last_edited=&#8221;on|phone&#8221; global_colors_info=&#8221;{}&#8221; sticky_enabled=&#8221;0&#8243;][\/et_pb_button][et_pb_button button_url=&#8221;https:\/\/intakeq.com\/new\/pckgpj&#8221; url_new_window=&#8221;on&#8221; button_text=&#8221;APLICACION PARA NI\u00d1OS&#8221; button_alignment=&#8221;center&#8221; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; custom_button=&#8221;on&#8221; button_text_size=&#8221;26px&#8221; button_border_width=&#8221;4px&#8221; button_border_color=&#8221;#283655&#8243; button_border_radius=&#8221;5px&#8221; button_icon=&#8221;&#x41;||divi||400&#8243; button_icon_color=&#8221;#F28D1D&#8221; custom_padding=&#8221;|42px||42px|false|true&#8221; button_text_size_tablet=&#8221;26px&#8221; button_text_size_phone=&#8221;18px&#8221; button_text_size_last_edited=&#8221;on|phone&#8221; global_colors_info=&#8221;{}&#8221;][\/et_pb_button][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row _builder_version=&#8221;4.19.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.19.4&#8243; _module_preset=&#8221;default&#8221; pac_dcm_carousel_specific_module_num=&#8221;0&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_divider color=&#8221;gcid-e2bc81b9-deae-4c56-9ec9-479689f0799f&#8221; divider_weight=&#8221;3px&#8221; _builder_version=&#8221;4.19.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{%22gcid-e2bc81b9-deae-4c56-9ec9-479689f0799f%22:%91%22color%22%93}&#8221;][\/et_pb_divider][et_pb_text _builder_version=&#8221;4.19.4&#8243; _module_preset=&#8221;default&#8221; text_font=&#8221;DM Sans|700||on|||||&#8221; text_text_color=&#8221;#f28d1d&#8221; header_font=&#8221;DM Sans|700||on|||||&#8221; header_2_font=&#8221;DM Sans|||on|||||&#8221; header_2_text_align=&#8221;left&#8221; header_3_font=&#8221;DM Sans|500|||||||&#8221; text_orientation=&#8221;center&#8221; custom_margin=&#8221;||-6px|||&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h2 class=\"vc_custom_heading\">PRIVACY POLICY &amp; HIPPA<\/h2>\n<div class=\"vc_tta-container\" data-vc-action=\"collapseAll\">\n<div class=\"vc_general vc_tta vc_tta-accordion vc_tta-color-grey vc_tta-style-modern vc_tta-shape-square vc_tta-o-shape-group vc_tta-controls-align-left vc_tta-o-all-clickable\">\n<div class=\"vc_tta-panels-container\">\n<div class=\"vc_tta-panels\">\n<div class=\"vc_tta-panel vc_active\" id=\"1614986873179-6b70eb5a-5afe\" data-vc-content=\".vc_tta-panel-body\">\n<div class=\"vc_tta-panel-heading\">\n<h4 class=\"vc_tta-panel-title vc_tta-controls-icon-position-left\"><\/h4>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][et_pb_row _builder_version=&#8221;4.19.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.19.4&#8243; _module_preset=&#8221;default&#8221; pac_dcm_carousel_specific_module_num=&#8221;0&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_accordion _builder_version=&#8221;4.19.4&#8243; _module_preset=&#8221;default&#8221; body_font=&#8221;DM Sans|500|||||||&#8221; body_font_size=&#8221;18px&#8221; custom_padding=&#8221;15px|10px|15px|10px|false|false&#8221; global_colors_info=&#8221;{%22gcid-e2bc81b9-deae-4c56-9ec9-479689f0799f%22:%91%22header_text_color%22,%22header_text_color%22%93}&#8221;][et_pb_accordion_item title=&#8221;Summary of HIPAA Notice of Privacy  Practices&#8221; open=&#8221;on&#8221; open_toggle_text_color=&#8221;gcid-e2bc81b9-deae-4c56-9ec9-479689f0799f&#8221; closed_toggle_text_color=&#8221;gcid-e2bc81b9-deae-4c56-9ec9-479689f0799f&#8221; _builder_version=&#8221;4.19.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{%22gcid-e2bc81b9-deae-4c56-9ec9-479689f0799f%22:%91%22toggle_text_color%22,%22open_toggle_text_color%22,%22closed_toggle_text_color%22%93}&#8221; toggle_text_color=&#8221;gcid-e2bc81b9-deae-4c56-9ec9-479689f0799f&#8221; toggle_font=&#8221;DM Sans|700|||||||&#8221; closed_toggle_font=&#8221;DM Sans|700|||||||&#8221;]<\/p>\n<p><span>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 \u201cProtected Health Information\u201d (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.<\/span><\/p>\n<p>[\/et_pb_accordion_item][et_pb_accordion_item title=&#8221;Summary of Your Privacy Rights&#8221; open_toggle_text_color=&#8221;gcid-e2bc81b9-deae-4c56-9ec9-479689f0799f&#8221; closed_toggle_text_color=&#8221;gcid-e2bc81b9-deae-4c56-9ec9-479689f0799f&#8221; _builder_version=&#8221;4.19.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{%22gcid-e2bc81b9-deae-4c56-9ec9-479689f0799f%22:%91%22toggle_text_color%22,%22open_toggle_text_color%22,%22closed_toggle_text_color%22%93}&#8221; toggle_text_color=&#8221;gcid-e2bc81b9-deae-4c56-9ec9-479689f0799f&#8221; toggle_font=&#8221;DM Sans|700|||||||&#8221; closed_toggle_font=&#8221;DM Sans|700|||||||&#8221; open=&#8221;off&#8221;]<\/p>\n<p><span>Shifa Free Clinic may use and give your health information to:<\/span><\/p>\n<ul>\n<li><span>Treat you<\/span><\/li>\n<li><span>Operate health care services<\/span><\/li>\n<\/ul>\n<p><span>Shifa Free Clinic may use and give your health information for:<\/span><\/p>\n<ul>\n<li><span>Law enforcement requests<\/span><\/li>\n<li><span>Judicial and administrative proceedings related to legal actions<\/span><\/li>\n<li><span>Healthcare fraud and abuse detection or compliance with the law<\/span><\/li>\n<li><span>Use by another healthcare provider treating you<\/span><\/li>\n<li><span>Government health oversight activities<\/span><\/li>\n<li><span>Reports required by law related to births, deaths or diseases<\/span><\/li>\n<li><span>Reports required by law related to neglect and abuse, or domestic violence<\/span><\/li>\n<li><span>Notifying a party about exposure to a possible communicable disease<\/span><\/li>\n<li><span>Military, national defense and security or other governmental functions<\/span><\/li>\n<li><span>Workers\u2019 compensation purposes and in compliance with related laws<\/span><\/li>\n<li><span>Averting a serious threat to public health and safety<\/span><\/li>\n<\/ul>\n<p><span>You have the right to:<\/span><\/p>\n<ul>\n<li><span>Inspect or get a copy of your medical record<\/span><\/li>\n<li><span>Change information on your medical record if you think it is incorrect<\/span><\/li>\n<li><span>Get a list of persons with whom Shifa Free Clinic has shared your PHI<\/span><\/li>\n<li><span>Ask Shifa Free Clinic to limit the information it shares<\/span><\/li>\n<li><span>Ask for a copy of your privacy notice<\/span><\/li>\n<li><span>Write a letter of complaint to Shifa Free Clinic or the federal government<\/span><\/li>\n<\/ul>\n<p><span>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<\/span><\/p>\n<p>[\/et_pb_accordion_item][\/et_pb_accordion][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>&nbsp; &nbsp; &nbsp; BECOME A SHIFA PATIENT &nbsp;<div class=\"et_pb_module df_adh_heading df_adh_heading_0\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t<div class=\"df-heading-container\">\r\n                \r\n                \r\n                <h3 class=\"df-heading\">  <\/h3>\r\n                \r\n            <\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>SHIFA FREE CLINIC ELIGIBILITY REQUIREMENTSTo be eligible for Shifa Free Clinic services, you must: \u00b7 Have no health insurance \u00b7 Have a total household income not exceeding 250% of the Federal Poverty Level \u00b7 Submit the Required Documents found below:<div class=\"et_pb_with_border et_pb_module difl_advancedtab difl_advancedtab_0\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t<h2 style=\"background:#eee; padding: 10px 20px;\">Please <strong>Add New Tab Item.<\/strong><\/h2>\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_with_border et_pb_module difl_advancedtabitem difl_advancedtabitem_0\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t<div class=\"df_ati_container\"><div class=\"df_at_content_wrapper\"><div class=\"df_at_content\">Can be any of the following: Driver\u2019s License DMV ID Card Passport Valid Green Card Other forms of identification on a case by case basis <\/div> <\/div><\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_with_border et_pb_module difl_advancedtabitem difl_advancedtabitem_1\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t<div class=\"df_ati_container\"><\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div> Employed: Paystubs (last 60 days) Weekly Pay: 4 Consecutive Paystubs Biweekly Pay: 2 Consecutive Paystubs If paid in Cash, use: Cash Form: English Cash Form: Spanish Typed Employer Letter Self-Employed: Previous Year Tax Return Unemployed: Typed letter of support from benefactor handsigned and notarized (I.E, If someone helps pay for or provides the applicant&#8217;s food and housing, that person must complete and sign a letter of [&hellip;]<\/p>\n","protected":false},"author":17,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_et_pb_use_builder":"on","_et_pb_old_content":"","_et_gb_content_width":"","_crdt_document":"","inline_featured_image":false,"_monsterinsights_skip_tracking":false,"footnotes":""},"difl_page_category":[],"class_list":["post-12488","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.2 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Patient Applications - Shifa Clinic - South Carolina<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.icnarelief.org\/shifaclinics\/patient-applications\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Patient Applications - Shifa Clinic - South Carolina\" \/>\n<meta property=\"og:description\" content=\"Diabetes Blood pressure Vision Anemia BMI Clinic info station We will be offering FREE Flu vaccines to any person 3 to 65 Years Old Fresh Produce Household Hygiene Kits Childcare Essentials Holiday Staples (While Supplies Last)Your support, whether through donations of volunteering, can bring hope and happiness to countless individuals and families. 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