Last Name First Name Date of Birth (yyyy-mon-dd)

Transcription

1 Public Health Dental Income Assessment If you live in the Calgary area, please complete this form to apply for funded services. If you have any questions, or don t know where to send this form, please call Health Link Alberta, in Calgary at Please see information at the bottom of Page 4 for data collection and use. Client information (print clearly) Chumir Dental Clinic th St. SW, 6th floor Phone: Calgary, AB T2R 0X7 Fax: Northeast Dental Clinic (at Sunridge Mall) #200, Street NE Phone: Calgary, AB T1Y 7M8 Fax: Please return completed form to the Chumir or Northeast Dental Clinic. Last Name First Name Date of Birth (yyyy-mon-dd) Address City/Town Postal Code Personal Health Number (PHN) - Home Phone Work Phone Cell Phone Marital Status (please check) Single Married Common-Law Separated Divorced Widowed Gender Male Female How did you hear about our program? Family members: List only those who are living in your household that are 18 years of age or older. If this does not apply to you please write N/A Last Name Check one box only: First Name Relationship (e.g., self, son, daughter, parent, spouse/partner) Date of Birth (yyyy-mon-dd) Section A: If you receive assistance from a government program, fill out Section A only. Section B: If you do not receive assistance from a government program and have a Notice of Assessment, fill out Section B only. Section C: If you do not receive assistance from a government program and/or do not have a Notice of Assessment, fill out Section C only ( ) Page 1 of 5

2 Section A Fill out this section only if you checked Section A on page 1. Please check the government program(s) from which you receive assistance. Alberta Adult Health Benefit: extended health benefits for people leaving AISH or Alberta Works Assured Income for the Severely Handicapped (AISH) Alberta Seniors Benefit (must be receiving monthly Cash Benefit) Alberta Student Finance Board Assistance (student loans) Alberta Works - Alberta Child Health Benefit Plan (with letter of renewal only) Alberta Works - Income Support Calgary Housing Company (for rent-subsidized unit) Child Care Subsidy for day care, day home, or after-school care for full subsidy City of Calgary Fee Assistance Federal Guaranteed Income Supplement (GIS) for Seniors First Nations Social Services Income Support Special Needs Assistance for Seniors Interim Federal Health Benefit (IFHB) Dental patients only To apply for physiotherapy services, please complete Section A (above), Section B or Section C and submit form along with your IFHB Certificate to a contracted clinic for manual processing of your application. ** You must attach a copy of your benefit card or confirmation letter from the government program. The letter must be dated less than 13 months ago. If you filled out page 1 and Section A, do not fill out any other section. Return the form to the Chumir or Northeast Dental Clinic address at the top of page ( ) Page 2 of 5

3 Section B Fill out this section only if you checked Section B on the page 1. If you are not on a Government program, you must provide information from your income tax return. If you do not have this information, go to Section C. Include the last review from Canada Revenue Agency for EACH household family member 18 years of age or older. If you do not have one, do not fill out Section B, go to Section C. Did you file an income tax return? Yes. For year: (provide the most recent tax year) No. If no, do not fill out Section B. Please complete Section C. What is your family size? (Include the number of all family members living in your household, no matter what age they are.) 1. Taxable income (line 260) of client (e.g. Notice of Assessment) 2. Taxable income (line 260) of spouse/partner (e.g. Notice of Assessment) Leave blank if you do not have a spouse/partner. 3. Taxable income (line 260) for all family members 18 years of age and older, as listed on page 1 (e.g. Notice of Assessment for each family member) 4. Combined annual taxable income for your household. (Add numbers 1, 2, and 3) I have given accurate and complete information about my household income. I know that it is against the law to give false information. If you filled out page 1 and Section B, do not fill out any other section. Return the form to the Chumir or Northeast Dental Clinic address at the top of page 1 along with a letter from your employer about what dental coverage you may have. If you need help with your taxes, the Canada Revenue Agency operates the Community Volunteer Income Tax Program to assist low income Canadians with completing their income tax returns at no cost. For information or to get a copy of your Notice of Assessment call the local office, or , or visit their website at ( ) Page 3 of 5

4 Section C Fill out this section only if you checked Section C on page 1. If you are having financial problems and/or do not have a Notice of Assessment, you may qualify for temporary eligibility for assistance. Proof of income will be needed (e.g. paper proof of income, letter from a Shelter or social worker, copy of your Employment Insurance statements, etc). Include all sources of income, in or outside of Canada, for the last three (3) months. Please give your income information for the last three (3) months. Year/Month Your Income for the Month You Listed Your Spouse/Partner s Monthly Income for the Month You Listed Income of Other Family Members Living in your Household (18 Years and Older) = = = 4 Total household income for the last three (3) months = Combined Monthly Household Income (Applicant, Spouse, Other Family Members) If your income is very low, how do you support yourself? Comments I have given accurate and complete information about my household income. I know that it is against the law to give false information. If you filled out page 1 and Section C, do not fill out any other section. Return the form to the Chumir or Northeast Dental Clinic address at the top of page 1. This personal information is being collected to determine and/or verify your eligibility to participate in an Alberta Health Services Calgary Zone program, or to receive a benefit, product or service from Alberta Health Services. This information is collected and used under the authority of the Alberta Freedom of Information and Protection of Privacy Act. If you have any questions about this collection of information, please contact Health Link Alberta in Calgary at 943.Link@albertahealthservices.ca or (LINK) or ( ) Page 4 of 5

5 INCOME ASSESSMENT FORM OFFICE USE ONLY 1. Client s name: 2. Client s date of birth (yyyy-mon-dd) or Home Care ID: 3. Date on application (yyyy-mon-dd): 4. Section completed by client: 4.1 ( ) Section A: if client checked one or more boxes, income is eligible. Proceed to item # ( ) Section B: if client provided income tax information, complete the following: Proceed to item #5 Family Size Combined annual household income 4.3 ( ) Section C: if client provided income declaration, complete the following: Family Size Average monthly household Income (Total row 4 divided by 3): 5. Determination of Income eligibility (for Sections B and C). If the applicant s family income is equal or less than the amounts indicated below, the applicant is eligible. Family Size* Section B Annual Taxable Income** Section C 3 Month Total Gross Income 1 24,328 6, ,286 7, ,234 9, ,206 11, ,272 12, ,826 14, ,381 16,095 * Family Size includes the number of adults and dependent children residing in the household ** Source: 2013 pre-tax Statistics Canada Low Income Cut-offs (LICO) 6. Client status: a) Income eligible b) Income exceeds limits c) Requires evidence of no dental plan NOTES Review completed by: (print name) Date: (yyyy-mon-dd) Signature: Staff ID#: Clinical Site: ( ) Page 5 of 5