Patient Registration

Patient Eligibility - Are you eligible to receive services?

 To be eligible to receive services from the Community Care Clinic of Dare, the patient must:

  • Be between 18 and 64 years old
  • Live or work in Dare County
  • Have no health insurance: Medicare; Medicaid; Veteran's; Private Insurance; Obamacare
  • Have less than $10,000 cash on hand or in a bank (Checking; Savings; CD; Money Market)
  • Have household income less than the limits* below.

Annually

Persons in Household Clinic / Medical Care (250%) MedAssist (200%)
1 $29,425 $23,540
2 $39,825 $31,860
3 $50,225 $40,180
4 $60,625 $48,500
5 $71,025 $56,820
6 $81,425 $65,140
7 $91,825 $73,460
8 $102,225 $81,780
Each Additional Person - Add: $10,400 $8,320

Monthly

Persons in Household Clinic / Medical Care (250%) MedAssist (200%)
1 $2,452 $1,962
2 $3,319 $2,655
3 $4,185 $3,348
4 $5,052 $4,042
5 $5,919 $4,735
6 $6,785 $5,428
7 $7,652 $6,122
8 $8,519 $6,815
Each Additional Person - Add: $867 $693

Weekly

Persons in Household Clinic / Medical Care (250%) MedAssist (200%)
1 $613 $491
2 $830 $664
3 $1,046 $837
4 $1,263 $1,011
5 $1,480 $1,184
6 $1,696 $1,357
7 $1,913 $1,531
8 $2,130 $1,704
Each additional person, add $217 $173

*These limits are based on the 2015 Federal Poverty Guidelines extended by the Department of Health and Human Services.

No person shall be subjected to discrimination on the basis of race, national origin, religion, sex, handicap, or disabilities. United States citizenship is not a requirement in meeting residency eligibility. The Community Care Clinic of Dare will attempt to provide limited-English-proficient patients with the assistance necessary to afford them meaningful access to services offered by the clinic.

Patient Registration - How to sign up for services

In order to verify that a patient meets the Community Care Clinic of Dare's eligibility requirements, the patient must register and provide documentation (listed below).

The patient's self-declaration of identity, Dare County residency and/or employment, income and resources, unless questionable, is acceptable for the initial visit.  The patient will not be seen or assisted again until the required documentation is provided to the Clinic.  If it is determined that the patient is eligible for services and completes full documentation, a certification of one (1) year will be given. Patient eligibility is subject to review at any time, and it is the responsibility of the patient to inform the Clinic of there is a change in his/her status that could affect eligibility.

Required Documentation for Registration

  • Unexpired photo identification
  • Social Security Card OR Taxpayer Identification Card
  • Proof of Residency
    Suggested documents: utility bill, tax bill, lease - something that has your name, street address, and a recent date and proves you reside at that address (rather than simply receiving mail there). If you do not have any of these documents, a third party who is in authority to provide verification of your residency may complete our Residency Declaration Form (copies are available at the Clinic).
    Note: United States citizenship is not a requirement in meeting residency eligibility.
  • Bank Account Statement
    We require the most recent statement (1 month) for all bank accounts that you or any household member have. If the balance of any or all accounts is more than $3,000, we may require a second statement.
  • Proof of Income
  • Most recent Federal Tax Returns or Form 4506T
The following documents (where applicable) are necessary to verify income for you and/or any other household member who receives any of the following:
Salary/Wages Consecutive pay stubs from the most recent 30 days OR self-employment records
Child Support Official letter with benefit amount, a cancelled check, OR bank statement showing deposit
Unemployment Income Official letter with benefit amount, a cancelled check, OR bank statement showing deposit
Supplemental Security Income Official letter with benefit amount, a cancelled check, OR bank statement showing deposit
SS Disability Income Official letter with benefit amount, a cancelled check, OR bank statement showing deposit
SS Retirement Income Official letter with benefit amount, a cancelled check, OR bank statement showing deposit
Food Stamps Official letter with benefit amount, a cancelled check, OR bank statement showing deposit
Veteran's Benefits Official letter with benefit amount, a cancelled check, OR bank statement showing deposit
Retirement/Pension Official letter with benefit amount, a cancelled check, OR bank statement showing deposit
Workmen's Compensation Official letter with benefit amount, a cancelled check, OR bank statement showing deposit
Rental Income Official letter with benefit amount, a cancelled check, OR bank statement showing deposit

patient registering

Registration Forms

Click on links for printable forms. Patients should print out ALL of the Community Care Clinic of Dare Registration Packet. Fill out all of the pages and bring to the clinic on registrations days, Tuesdays and Thursdays from 9-1

General Information

Community Care Clinic of Dare Registration Packet

 
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P.O. Box 1329 | 425 Health Center Drive | Nags Head NC 27959
252-261-3041

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