Patient Eligibility

In what county does the patient live? *
Is the patient currently insured *

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

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 *

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.
 
    *For families/households with more than 8 persons, add $4,180 for each additional person.
 
Select *

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 *

Is the procedure being requested out-patient and elective?
Select *

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