MVP – Sliding Fee Discount ProgramThe MVP Program is a federally supported program that allows Ocracoke Health Center (OHC) and Engelhard Medical Center (EMC) to discount charges for medical visits at OHC/EMC. You may also be eligible for discounts in our dental or pharmacy programs. In order to be eligible for the MVP, you must provide accurate and acceptable proof of family income and a list of all persons in the family. If you did not bring proof of income with you at this visit today, you may self-declare your income, but proof must be provided within thirty (30) days of the visit. If you do not provide proof of income with in the 30 days, you will be responsible for 100% of all charges billed to you after that. You are required to report any changes in family income or number of members in the family when they occur. Falsification of this information may result in loss of MVP privileges.EligibilityAll OHC/EMC patients are eligible to apply for the MVP. Determination of the discount, if any, is dependent upon family income and family size in comparison to the current Federal Poverty Guidelines. The discount may apply to Insurance/Medicare deductibles as well Medicaid/Medicare non-covered services.TermInformation must be updated every twelve (12) months or with any change of family income or family size.Definitions and Examples of Acceptable Proof of IncomeIncome is based on the gross income of all family members who are earning income. Includes earnings, unemployment compensation, workers’ compensation, Social Security, Supplemental Security Income, public assistance, veterans’ payments, survivor benefits, pension or retirement income, interest, dividends, rents, royalties, income from estates, trusts, educational assistance, alimony, child support, assistance from outside the household, and other miscellaneous sources. Noncash benefits (such as food stamps and housing subsidies) are not included. Acceptable forms of proof for determining income include the following: Income Tax Return: A signed copy of the most recent tax return showing Adjusted Gross Income. Copy of most recent W-2/1099. Pay check stubs: Two or more consecutive pay stubs indicating gross pay within the past sixty (60) days. Agency letter: A letter from the Social Security Administration, Veterans Administration or Social Service Agency (i.e., TANF, Food Stamps, or WIC) indicating income level. Unemployment Verification: Paperwork from the Employment Securities Commission (ESC) proving unemployment status and the amount of unemployment compensation being received. Court Documents: Official documents citing child support or alimony as awarded by a judge. Official Paperwork: Paperwork documenting retirement, disability, SSI benefits. Employer Letter: For those not receiving an actual pay check, a letter from the patient’s employer detailing current gross income and frequency of pay periods may be accepted. Contact information must be provided so that information can be verified.Family Size DeterminationAll members of a household who are pooling financial resources including room and board and/or are supporting one another financially are counted as a family.Name* First Last Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email* Are you...* Declaring Income Claiming Zero Income Eligibility DeterminationPlease fill out for each family member. Click the green + to add another family member.*NameYearly IncomeDocumentation TypeDate of Birth Total Income* Total Household Size* File Upload - Upload Pictures of Proof of IncomePlease take a picture of paycheck stubs, social security letters, letter from employer, unemployment, etc. You can upload all the images here. Drop files here or Select files Max. file size: 5 GB. For Internal Use OnlyDate Documents Received Received by TO BE COMPLETED BY PATIENT/GUARDIANPlease complete ALL family information below*Documentation must be provided by patient or guardian to determine eligibility for Sliding Fee Scale* I understand that the information I provide on this form is subject to verification by OHC/EMC. I certify that the above information is true and correct to the best of my knowledge and that I understand & agree that providing false information can result in me being denied ability to apply for the program; furthermore I agree to adhere to all terms and conditions of the MVP Program.Patient/Guardian Signature*Name* First Last Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920I certify that I am self-declaring my income and that I will provide proof within the thirty days to verify this amount. I declare that I receive the annual household income listed above and my family members are listed above. I understand that I will be responsible for a portion of all charges (nominal fee) for care that I incur. I understand that this application is applicable for the visit today. I will have to provide proof of income within the next 30 days to remain in the MVP discount program for one year. If my income status changes at any time, I will notify the health center immediately.Patient/Guardian Signature*Name* First Last Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920For Internal Use Only(to be completed by OHC/EMC)Total Income Total Family Size Medical Slide Category (1-5) Slide Effective Date (30 days prior) Slide Termination Date (Effective 1 year) Signature of OHC/EMC Employee Printed Name Date ZERO INCOME CERTIFICATIONBy signing this Zero Income Certification, I declare that: I receive no income from any source. I understand that I will be responsible for a portion (nominal fee) of all charges for care that I incur. I understand that this Certification is only applicable for three months from the date I sign the application. If my income status changes at any time, I will notify the health center immediately.Name* First Last Phone Number*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Social Security Number (optional) Patient/Guardian Signature*Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920For Internal Use OnlyZero Income Certification Expires On Patient Notified of Expiration of Zero Income Certification? OHC/EMC Employee Signature Date CAPTCHAEmailThis field is for validation purposes and should be left unchanged.