Operation Access - Patient Eligibility

In what county does the patient live?

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Is the patient currently insured

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Yes
No

Can the patient qualify for employer-sponsored, Medi-Cal, Healthy Families, Medicare, or any other publicly-funded insurance?

Select

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Yes
No

If the patient lives in Marin or Sonoma, can s/he qualify for County Medical Services Program (CMSP)? (Please choose NO if the patient does not live in Marin or Sonoma.):

Select

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Yes
No

Is the patient's total gross household income at or below 250% of the Federal Poverty Level (FPL)? - Please include all wages, social security benefits, disability, and any other financial assistance.

2011 Federal Poverty Level Guidelines

	YEARLY Gross Income	MONTHLY Gross Income
# in household	250% FPL	250% FPL
1	$27,225	$2,269
2	$36,775	$3,065
3	$46,325	$3,860
4	$55,875	$4,656
5	$65,425	$5,452
6	$74,975	$6,248
7	$84,525	$7,044
8	$94,075	$7,840

Select

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Yes
No

Is the total amount of money that the patient has in savings less than $5,000? - please include checking and savings accounts, retirement funds, CDs, etc.

Select

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Yes
No

Is the procedure being requested out-patient and elective?

Select

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Yes
No

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