[et_pb_section fb_built=”1″ _builder_version=”4.19.4″ _module_preset=”default” custom_padding=”0px|||||” global_colors_info=”{}”][et_pb_row _builder_version=”4.19.4″ _module_preset=”default” global_colors_info=”{}”][et_pb_column type=”4_4″ _builder_version=”4.19.4″ _module_preset=”default” global_colors_info=”{}”][et_pb_text _builder_version=”4.19.4″ _module_preset=”default” text_font=”DM Sans|700||on|||||” text_text_color=”#f28d1d” header_font=”DM Sans|700||on|||||” text_orientation=”center” custom_margin=”||-6px|||” global_colors_info=”{}”]<\/p>\n
[\/et_pb_text][et_pb_divider color=”gcid-e2bc81b9-deae-4c56-9ec9-479689f0799f” divider_weight=”3px” _builder_version=”4.19.4″ _module_preset=”default” global_colors_info=”{%22gcid-e2bc81b9-deae-4c56-9ec9-479689f0799f%22:%91%22color%22%93}”][\/et_pb_divider][\/et_pb_column][\/et_pb_row][et_pb_row _builder_version=”4.20.2″ _module_preset=”default” global_colors_info=”{}”][et_pb_column type=”4_4″ _builder_version=”4.20.2″ _module_preset=”default” global_colors_info=”{}”][et_pb_image src=”https:\/\/www.icnarelief.org\/shifaclinics\/wp-content\/uploads\/sites\/2\/2024\/01\/843-352-4580-1.png” title_text=”843-352-4580 (1)” _builder_version=”4.20.2″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_image][\/et_pb_column][\/et_pb_row][et_pb_row _builder_version=”4.20.2″ _module_preset=”default” global_colors_info=”{}”][et_pb_column type=”4_4″ _builder_version=”4.20.2″ _module_preset=”default” global_colors_info=”{}”][et_pb_text _builder_version=”4.20.2″ _module_preset=”default” text_font=”|700|||||||” text_font_size=”16px” background_color=”#FFFFFF” box_shadow_style=”preset1″ box_shadow_color=”#055205″ global_colors_info=”{}”]<\/p>\n
[\/et_pb_text][et_pb_divider color=”#E09900″ divider_style=”groove” divider_weight=”2px” _builder_version=”4.20.2″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_divider][\/et_pb_column][\/et_pb_row][et_pb_row _builder_version=”4.20.2″ _module_preset=”default” global_colors_info=”{}”][et_pb_column type=”4_4″ _builder_version=”4.20.2″ _module_preset=”default” global_colors_info=”{}”][et_pb_text _builder_version=”4.20.2″ _module_preset=”default” text_font=”|700|||||||” text_font_size=”16px” background_color=”#FFFFFF” box_shadow_style=”preset1″ box_shadow_color=”#055205″ global_colors_info=”{}”]<\/p>\n
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[\/et_pb_text][et_pb_button button_url=”https:\/\/fplcalculator.com\/” url_new_window=”on” button_text=”Check your household income eligibility.” button_alignment=”center” _builder_version=”4.20.2″ _module_preset=”default” custom_button=”on” button_text_size=”32px” button_text_color=”#000000″ button_bg_color=”#ffcc00″ button_border_radius=”11px” button_letter_spacing=”1px” button_font=”|700|||||||” button_icon=”6||divi||400″ button_icon_color=”#000000″ button_on_hover=”off” box_shadow_style=”preset2″ box_shadow_horizontal=”-7px” global_colors_info=”{}”][\/et_pb_button][\/et_pb_column][\/et_pb_row][et_pb_row _builder_version=”4.20.2″ _module_preset=”default” global_colors_info=”{}”][et_pb_column type=”4_4″ _builder_version=”4.20.2″ _module_preset=”default” global_colors_info=”{}”][et_pb_divider color=”#E09900″ divider_style=”groove” divider_weight=”2px” _builder_version=”4.20.2″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_divider][et_pb_text _builder_version=”4.20.2″ _module_preset=”default” text_font=”|700|||||||” text_font_size=”16px” background_color=”#FFFFFF” box_shadow_style=”preset1″ box_shadow_color=”#055205″ global_colors_info=”{}”]<\/p>\n
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[\/et_pb_text][\/et_pb_column][\/et_pb_row][et_pb_row column_structure=”1_2,1_2″ _builder_version=”4.20.2″ _module_preset=”default” global_colors_info=”{}”][et_pb_column type=”1_2″ _builder_version=”4.20.2″ _module_preset=”default” global_colors_info=”{}”][et_pb_image src=”https:\/\/www.icnarelief.org\/shifaclinics\/wp-content\/uploads\/sites\/2\/2024\/01\/Have-no-health-insurance-Have-an-income-level-that-falls-within-250-of-the-Federal-Poverty-Level-based-on-the-number-o-3.png” title_text=”Have no health insurance Have an income level that falls within 250% of the Federal Poverty Level based on the number o (3)” _builder_version=”4.20.2″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_image][\/et_pb_column][et_pb_column type=”1_2″ _builder_version=”4.20.2″ _module_preset=”default” global_colors_info=”{}”][et_pb_image src=”https:\/\/www.icnarelief.org\/shifaclinics\/wp-content\/uploads\/sites\/2\/2024\/01\/Have-no-health-insurance-Have-an-income-level-that-falls-within-250-of-the-Federal-Poverty-Level-based-on-the-number-o-4.png” title_text=”Have no health insurance Have an income level that falls within 250% of the Federal Poverty Level based on the number o (4)” _builder_version=”4.20.2″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_image][\/et_pb_column][\/et_pb_row][et_pb_row _builder_version=”4.20.2″ _module_preset=”default” background_color=”#569639″ global_colors_info=”{}”][et_pb_column type=”4_4″ _builder_version=”4.20.2″ _module_preset=”default” global_colors_info=”{}”][et_pb_cta title=”If you have no ID or proof of Address” button_url=”https:\/\/acrobat.adobe.com\/link\/track?uri=urn:aaid:scds:US:2a6bb6f8-934d-326c-963d-b41c8f042152″ url_new_window=”on” button_text=”Verification Form” _builder_version=”4.20.2″ _module_preset=”default” body_text_color=”#000000″ body_font_size=”21px” body_letter_spacing=”1px” background_color=”#FFFFFF” custom_button=”on” button_text_color=”#FFFFFF” button_bg_color=”#E09900″ button_icon=”A||divi||400″ custom_margin=”-8px||||false|false” custom_padding=”0px||16px||false|false” global_colors_info=”{}”]<\/p>\n
If you do not possess a valid ID due to various circumstances, including homelessness, please have a credible person complete the form to support your claim<\/span><\/p>\n [\/et_pb_cta][\/et_pb_column][\/et_pb_row][et_pb_row _builder_version=”4.20.2″ _module_preset=”default” global_colors_info=”{}”][et_pb_column type=”4_4″ _builder_version=”4.20.2″ _module_preset=”default” global_colors_info=”{}”][et_pb_cta title=”PROOF OF INCOME” button_text=”Click Here” _builder_version=”4.20.2″ _module_preset=”default” header_font=”|700|||||||” header_text_color=”#000000″ header_font_size=”32px” background_color=”#efeeea” background_layout=”light” box_shadow_style=”preset5″ box_shadow_color=”#cdc0b4″ global_colors_info=”{}”]<\/p>\n [\/et_pb_cta][\/et_pb_column][\/et_pb_row][et_pb_row _builder_version=”4.20.2″ _module_preset=”default” global_colors_info=”{}”][et_pb_column type=”4_4″ _builder_version=”4.20.2″ _module_preset=”default” global_colors_info=”{}”][et_pb_accordion _builder_version=”4.20.2″ _module_preset=”default” hover_enabled=”0″ global_colors_info=”{}” sticky_enabled=”0″][et_pb_accordion_item title=”If you and\/or any household member is employed ” open=”off” open_toggle_text_color=”#000000″ open_toggle_background_color=”#FFFFFF” closed_toggle_text_color=”#FFFFFF” closed_toggle_background_color=”#E09900″ icon_color=”#FFFFFF” toggle_icon=”7||divi||400″ use_icon_font_size=”on” icon_font_size=”59px” _builder_version=”4.20.2″ _module_preset=”default” global_colors_info=”{}” toggle_font_size=”22px” closed_toggle_font=”|600|||||||” closed_toggle_font_size=”25px”]<\/p>\n [\/et_pb_accordion_item][et_pb_accordion_item title=”Odd jobs\/work for family, friends or neighbors” open_toggle_text_color=”#000000″ open_toggle_background_color=”#FFFFFF” closed_toggle_text_color=”#FFFFFF” closed_toggle_background_color=”#000000″ toggle_icon=”7||divi||400″ use_icon_font_size=”on” icon_font_size=”65px” _builder_version=”4.20.2″ _module_preset=”default” body_text_color=”#000000″ body_font_size=”17px” hover_enabled=”0″ global_colors_info=”{}” toggle_text_color=”#FFFFFF” toggle_font=”|700|||||||” toggle_font_size=”25px” closed_toggle_font_size=”25px” open=”off” sticky_enabled=”0″]<\/p>\n No handwritten letters are accepted.<\/p>\n [\/et_pb_accordion_item][et_pb_accordion_item title=”If you are self employed” open_toggle_text_color=”#000000″ open_toggle_background_color=”#FFFFFF” closed_toggle_background_color=”#E09900″ icon_color=”#FFFFFF” toggle_icon=”7||divi||400″ use_icon_font_size=”on” icon_font_size=”65px” _builder_version=”4.20.2″ _module_preset=”default” hover_enabled=”0″ global_colors_info=”{}” toggle_text_color=”#FFFFFF” toggle_font_size=”28px” open=”off” sticky_enabled=”0″]<\/p>\n [\/et_pb_accordion_item][et_pb_accordion_item title=” If you have No Income” open_toggle_text_color=”#000000″ open_toggle_background_color=”#FFFFFF” closed_toggle_text_color=”#FFFFFF” closed_toggle_background_color=”#000000″ toggle_icon=”7||divi||400″ use_icon_font_size=”on” icon_font_size=”68px” _builder_version=”4.20.2″ _module_preset=”default” hover_enabled=”0″ global_colors_info=”{}” closed_toggle_font_size=”33px” open=”on” sticky_enabled=”0″]<\/p>\n [\/et_pb_accordion_item][et_pb_accordion_item title=” SNAP \/ SSI \/Others ” open_toggle_text_color=”#000000″ closed_toggle_text_color=”#FFFFFF” closed_toggle_background_color=”#E09900″ toggle_icon=”7||divi||400″ use_icon_font_size=”on” icon_font_size=”68px” _builder_version=”4.20.2″ _module_preset=”default” global_colors_info=”{}” closed_toggle_font_size=”33px” open=”off”]<\/p>\n [\/et_pb_accordion_item][\/et_pb_accordion][\/et_pb_column][\/et_pb_row][et_pb_row _builder_version=”4.20.2″ _module_preset=”default” global_colors_info=”{}”][et_pb_column type=”4_4″ _builder_version=”4.20.2″ _module_preset=”default” global_colors_info=”{}”][et_pb_divider color=”#E09900″ divider_style=”groove” divider_weight=”2px” _builder_version=”4.20.2″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_divider][et_pb_text _builder_version=”4.20.2″ _module_preset=”default” text_font=”|700|||||||” text_font_size=”16px” background_color=”#FFFFFF” box_shadow_style=”preset1″ box_shadow_color=”#055205″ global_colors_info=”{}”]<\/p>\n <\/p>\n [\/et_pb_text][\/et_pb_column][\/et_pb_row][et_pb_row column_structure=”1_2,1_2″ _builder_version=”4.20.2″ _module_preset=”default” global_colors_info=”{}”][et_pb_column type=”1_2″ _builder_version=”4.20.2″ _module_preset=”default” global_colors_info=”{}”][et_pb_button button_url=”https:\/\/intakeq.com\/new\/pr96w8″ button_text=”Patient Application English” _builder_version=”4.20.2″ _module_preset=”default” custom_button=”on” button_text_size=”30px” button_text_color=”#FFFFFF” button_bg_color=”#f28d1d” button_border_width=”3px” button_icon=”>||divi||400″ global_colors_info=”{}”][\/et_pb_button][\/et_pb_column][et_pb_column type=”1_2″ _builder_version=”4.20.2″ _module_preset=”default” global_colors_info=”{}”][et_pb_button button_url=”https:\/\/intakeq.com\/new\/1jvhmt” button_text=”Patient Application Spanish” _builder_version=”4.20.2″ _module_preset=”default” custom_button=”on” button_text_size=”30px” button_text_color=”#FFFFFF” button_bg_color=”#f28d1d” button_border_width=”3px” button_icon=”>||divi||400″ global_colors_info=”{}”][\/et_pb_button][\/et_pb_column][\/et_pb_row][et_pb_row _builder_version=”4.19.4″ _module_preset=”default” global_colors_info=”{}”][et_pb_column type=”4_4″ _builder_version=”4.19.4″ _module_preset=”default” global_colors_info=”{}”][et_pb_divider color=”gcid-e2bc81b9-deae-4c56-9ec9-479689f0799f” divider_weight=”3px” _builder_version=”4.19.4″ _module_preset=”default” global_colors_info=”{%22gcid-e2bc81b9-deae-4c56-9ec9-479689f0799f%22:%91%22color%22%93}”][\/et_pb_divider][et_pb_text _builder_version=”4.19.4″ _module_preset=”default” text_font=”DM Sans|700||on|||||” text_text_color=”#f28d1d” header_font=”DM Sans|700||on|||||” header_2_font=”DM Sans|||on|||||” header_2_text_align=”left” header_3_font=”DM Sans|500|||||||” text_orientation=”center” custom_margin=”||-6px|||” global_colors_info=”{}”]<\/p>\n [\/et_pb_text][\/et_pb_column][\/et_pb_row][et_pb_row _builder_version=”4.19.4″ _module_preset=”default” global_colors_info=”{}”][et_pb_column type=”4_4″ _builder_version=”4.19.4″ _module_preset=”default” global_colors_info=”{}”][et_pb_accordion _builder_version=”4.19.4″ _module_preset=”default” body_font=”DM Sans|500|||||||” body_font_size=”18px” custom_padding=”15px|10px|15px|10px|false|false” global_colors_info=”{%22gcid-e2bc81b9-deae-4c56-9ec9-479689f0799f%22:%91%22header_text_color%22,%22header_text_color%22%93}”][et_pb_accordion_item title=”Summary of HIPAA Notice of Privacy Practices” open=”on” open_toggle_text_color=”gcid-e2bc81b9-deae-4c56-9ec9-479689f0799f” closed_toggle_text_color=”gcid-e2bc81b9-deae-4c56-9ec9-479689f0799f” _builder_version=”4.19.4″ _module_preset=”default” global_colors_info=”{%22gcid-e2bc81b9-deae-4c56-9ec9-479689f0799f%22:%91%22toggle_text_color%22,%22open_toggle_text_color%22,%22closed_toggle_text_color%22%93}” toggle_text_color=”gcid-e2bc81b9-deae-4c56-9ec9-479689f0799f” toggle_font=”DM Sans|700|||||||” closed_toggle_font=”DM Sans|700|||||||”]<\/p>\n 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 [\/et_pb_accordion_item][et_pb_accordion_item title=”Summary of Your Privacy Rights” open_toggle_text_color=”gcid-e2bc81b9-deae-4c56-9ec9-479689f0799f” closed_toggle_text_color=”gcid-e2bc81b9-deae-4c56-9ec9-479689f0799f” _builder_version=”4.19.4″ _module_preset=”default” global_colors_info=”{%22gcid-e2bc81b9-deae-4c56-9ec9-479689f0799f%22:%91%22toggle_text_color%22,%22open_toggle_text_color%22,%22closed_toggle_text_color%22%93}” toggle_text_color=”gcid-e2bc81b9-deae-4c56-9ec9-479689f0799f” toggle_font=”DM Sans|700|||||||” closed_toggle_font=”DM Sans|700|||||||” open=”off”]<\/p>\n Shifa Free Clinic may use and give your health information to:<\/span><\/p>\n Shifa Free Clinic may use and give your health information for:<\/span><\/p>\n You have the right to:<\/span><\/p>\n 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 [\/et_pb_accordion_item][\/et_pb_accordion][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":" Patient ApplicationsSTEP\u00a0 1\u00a0 INSURANCE STATUS \u00a0Confirm on your application that you are uninsured and in addition do not have Medicare Medicaid (except Family Planning\/ Healthy Connections Checkup), VA Health Benefits, Private Health Insurance or Affordable Care Act STEP\u00a0 2 INCOME ELIGIBILITY \u00a0 Have an income that falls below 250% FPL based on the number of people in your household. Every member of the family who is working needs to have the income added to the household. STEP\u00a0 3 PREPARE YOUR DOCUMENTS A) Proof of Identity :\u00a0\u00a0 B) Proof of Address c) Proof of Income \u00a0\u00a0 If you do not possess a valid ID due to various circumstances, including homelessness, please have a credible person complete the form to support your claimFor each working member of your household proof of Income is required Check below what document will apply to your particular caseA)\u00a0 If you receive pay stubs:\u00a0 \u00a0Send 2 current consecutive pay stubs no older than 45 days, with no weeks missing in between, for all members who are working.OR\u00a0 most recent Tax document or W-2 B) If paid in cash : You may instead send a signed and dated letter from your\/your household’s employer stating what work is […]<\/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":"","_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"class_list":["post-12488","page","type-page","status-publish","hentry"],"rttpg_featured_image_url":null,"rttpg_author":{"display_name":"jakob","author_link":"https:\/\/www.icnarelief.org\/shifaclinics\/author\/jakob\/"},"rttpg_comment":0,"rttpg_category":null,"rttpg_excerpt":"Patient ApplicationsSTEP\u00a0 1\u00a0 INSURANCE STATUS \u00a0Confirm on your application that you are uninsured and in addition do not have Medicare Medicaid (except Family Planning\/ Healthy Connections Checkup), VA Health Benefits, Private Health Insurance or Affordable Care Act STEP\u00a0 2 INCOME ELIGIBILITY \u00a0 Have an income that falls below 250% FPL based on the number of…","_links":{"self":[{"href":"https:\/\/www.icnarelief.org\/shifaclinics\/wp-json\/wp\/v2\/pages\/12488","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.icnarelief.org\/shifaclinics\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.icnarelief.org\/shifaclinics\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.icnarelief.org\/shifaclinics\/wp-json\/wp\/v2\/users\/17"}],"replies":[{"embeddable":true,"href":"https:\/\/www.icnarelief.org\/shifaclinics\/wp-json\/wp\/v2\/comments?post=12488"}],"version-history":[{"count":94,"href":"https:\/\/www.icnarelief.org\/shifaclinics\/wp-json\/wp\/v2\/pages\/12488\/revisions"}],"predecessor-version":[{"id":20374,"href":"https:\/\/www.icnarelief.org\/shifaclinics\/wp-json\/wp\/v2\/pages\/12488\/revisions\/20374"}],"wp:attachment":[{"href":"https:\/\/www.icnarelief.org\/shifaclinics\/wp-json\/wp\/v2\/media?parent=12488"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}For each working member of your household proof of Income is required<\/span><\/span><\/h3>\n
Check below what document will apply to your particular case<\/span><\/span><\/h3>\n
A)\u00a0 If you receive pay stubs<\/strong>:\u00a0 \u00a0Send 2 current consecutive pay stubs no older than 45 days, with no weeks missing<\/h4>\n
in between, for all members who are working.OR\u00a0 most recent Tax document or W-2<\/h4>\n
B) If paid in cash<\/strong> : You may instead send a signed and dated letter from your\/your household’s employer stating what<\/h4>\n
work is done, if there are any deductions from pay, the GROSS rate of pay, and the number of hours worked for the last<\/h4>\n
4 weeks on their Letter head Or you can print the following CASH BY EMPLOYER FORM <\/strong><\/a>and get it signed by Employer<\/h4>\n
Send a signed and dated letter from those you\/your household do work for stating what work is<\/h3>\n
done, the GROSS rate of pay (with any deductions listed), and the number of hours worked for<\/h3>\n
last 4 weeks Or Fill have them fill out the Exchange form<\/a><\/strong><\/span><\/h3>\n
– Send your\/your household’s most recent Federal 1040 tax return and the Schedule C – Business Profit or Loss worksheet<\/h3>\n
OR you may send a completed copy of\u00a0 Shifa clinic’s<\/h3>\n
Self declaration of income <\/a><\/strong><\/span><\/h3>\n
Call Us if you unable to access the form<\/h3>\n
– If no one in your home has any income, submit a fully completed No-Income-Form-Apr-22 No-Income-Form-Apr-22 (3).<\/a><\/strong><\/span><\/h4>\n
We need to know how you are paying for your housing, food, and utilities. The person providing support cannot live in the same household as the patient.
Call Us if you are not able to access the form<\/h4>\n-If you have SNAP or SSI letter that will qualify you for our services and you can upload that letter as proof of income<\/h4>\n
Social Security Retirement\/Social Security Disability – Send the Social Security New Benefit Amount letter showing
MONTHLY amount received for the CURRENT year.<\/h4>\nOther Retirement\/Pension\/ Annuity – Send the current benefit statement showing the monthly amount received with any
deductions OR a copy of Form 1099. We cannot accept copies of checks or bank statements.<\/h4>\nChild Support\/Alimony – Send a copy of a current statement from the clerk of court or a copy of the entire divorce decree
stating amount received and how often.<\/h4>\n<\/h1>\n
<\/u><\/strong><\/h1>\n
<\/u><\/strong><\/h1>\n
\u00a0All documents can be securely uploaded on our website through the application link.<\/h4>\n
<\/h4>\n
Once your completed application is received and checked for completeness we will be contacting you for your appointment scheduling.<\/h4>\n
All services at Shifa once your eligibility is verified is at no cost to you. If you have any questions please call us at 843-3524580 or email at shifa.sc@icnarelief.org<\/a>\u00a0 You can also print the application and scan or fax us at 843-375-9063<\/h4>\n
\u00a0\u00a0<\/strong><\/h3>\n
PRIVACY POLICY & HIPPA<\/h2>\n
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