AFFIX LABEL OR COMPLETE PATIENT NAME ID NUMBER KY

9 CHAPTER 2 WORD ROOTS AFFIXES AND COMBINING FORMS
AFFIX LABEL OR COMPLETE PATIENT NAME ID NUMBER KY
AFFIX PASSPORT SIZE PHOTOGRAPH JEEVASARTHAKATHE HEALTH AND FAMILY WELFARE

Affix Patient Label Here Note Label Required for Cover
AFFIX PHOTOGRAPH (CHOOSE FILE) HOSTEL ADMISSION FORM­ (NUST ISLAMABAD
AFFIX PHOTOGRAPH HERE (COPY AND PASTE) EMPLOYMENT APPLICATION FORM

CH-NP Statement of No Proof of Income


Affix label or complete:



Patient name:____________________


ID Number:______________________







KY Department for Public Health

Local Health Department

Statement of NO Proof


For an applicant who has proof of income, but fails to bring it at the time of service, inform the participant of proof requirements, and make a new appointment within the timeframe for appointment scheduling.


The ______________________________________ health department requires each applicant to show proof of household income to receive medical services. Please read the following statement before completing this form.


I understand that by completing, signing, and dating this form, I am certifying that the information I am providing below is correct.

I understand that giving false information may jeopardize my ability to continue receiving medical services.









Completion of this form is for:

Income – applicant’s total household income is:

If reporting zero income, explain how your household expenses are being paid below.


Reason for No Proof of the above:



Applicant:

(Signature) (Date)

AFFIX LABEL OR COMPLETE PATIENT NAME ID NUMBER KY

CH-NP

7/1/2013


Statement of No Proof Form Instructions



TAFFIX LABEL OR COMPLETE PATIENT NAME ID NUMBER KY he purpose of this form is to document the reason proof of total household income cannot be provided. This form should not be used on a routine basis. To complete this form:

  1. Attach a patient label or write the patient’s name and ID number in the space provided.

  2. Ask the applicant to read the policy and warning (or read to the applicant if they are unable to read).

  3. Applicant (or staff if applicant is unable to write) writes a detailed statement explaining why he/she is unable to provide proof. If applicant reports zero household income, the statement should include how basic living necessities such as food, shelter, medical care, and clothing are obtained.

  4. Applicant signs and dates on the line provided.

AAFFIX LABEL OR COMPLETE PATIENT NAME ID NUMBER KY pplicant Unable to Provide Proof of Income

  • An applicant who has no written proof of income, such as a migrant, a homeless person, or a person who works for cash, or who reports income as zero, can self declare income and must provide a signed statement. An applicant where military service personnel are temporarily absent from home and proof of gross military income cannot be produced, may self-declare income and must provide a signed statement.

  • The statement must include why written proof of income cannot be provided, (i.e., homeless, migrant), the date, and the person’s signature. For zero income, an explanation of how living necessities such as food, shelter, medical care and clothing are obtained.


AFFIX LABEL OR COMPLETE PATIENT NAME ID NUMBER KY AFFIX LABEL OR COMPLETE PATIENT NAME ID NUMBER KY AFFIX LABEL OR COMPLETE PATIENT NAME ID NUMBER KY

The Statement of No Proof must be filed in the patient’s medical record and applies to the period for which it was provided.



AFFIX TWO STAMP SIZE PHOTOGRAPHS POSTGRADUATE DIPLOMA IN CURRICULUM
AFFIX WORKSHOP MAY 28TH 2004 SARAH SWANBERG INSTRUCTOR PREFIXES
ANNEXE IX LABEL TO BE AFFIXED TO THE OUTER


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