Patient Certification Policy

SOUTHSIDE MEDICAL CENTER

PATIENT CERTIFICATION POLICY

As a Federally Qualified Community Health Center we are required by law to obtain all of this information for our records.  When you make an appointment or walk-in to the facility, it may be necessary for you to be certified.  Patients with appointments should report at least 30 minutes early so your information can be verified and you can see your provider on a timely basis.  If you do not have the necessary information available, please be prepared to pay the full charges at the time of service.  You have (7) seven days to bring all the required information to us. 

We can only determine your eligibility for the sliding fee scale once we receive all of the required information.  Should you qualify for the sliding fee scale and a refund is due, we will process a refund check accordingly within (5) working days from the date of receipt of all required information. 

PATIENTS W/INSURANCE, MEDICARE, & MEDICAID
(Bring the following documents at each visit)

1. Photo ID
2. Insurance Card

SLIDING FEE PATIENTS

1. Proof of Identification and Address Verification:

Current Photo ID with address or Current Photo ID with any utility bill or rental lease agreement (or notarized letter from landlord) or any other business documents that verifies your place of residency.

1. Proof of Income: (One of the following is required)
2. Minimum of two current paycheck stubs and proof of income for all in your household (or typed, notarized letter from your employer)
3. Income Tax Return or W2 Form (most recent)
4. Disability/Worker’s Compensation Notification Form or Social Security Notification Form or Pension/ Retirement Statement or Veteran’s Benefits Statement or Child Support Court Award (must include amount of benefits)
5. Current Food Stamp Summary
6. Other documents showing how the patient is being supported

1. Proof of Number of Dependents: (One of the following is required)
2. Previous year’s Income Tax Return (most recent)
3. Any decision letters indicating that the patient has legal responsibility for the child, such as, court order guardianship papers or custody papers
4. Birth Certificate for each child age 18 and younger

SELF-EMPLOYED PERSONS

1. Most recent federal tax return to verify income and unemployment insurance wage determination from the Georgia Dept. of Labor.

UNEMPLOYED PERSONS

1. Unemployment insurance wage determination from the Georgia Dept. of Labor and the most recent federal tax return to verify income or a current 30-day separation notice.

SOUTHSIDE MEDICAL CENTER

COLLEGE STUDENTS

(Bring the following documents at each visit)

1. A current student Photo ID
2. Proof of being a full-time student and a minimum of two current paycheck stubs if employed or unemployment insurance wage determination from the Georgia Dept. of Labor if you are not employed while attending school.

UNDOCUMENTED IMMIGRANTS and THE HOMELESS

(Bring the following documents at each visit)

1. Photo ID
2. Letter of reference from one of the following:  Employer, Minister, Priest, Homeless Program, Shelters, etc. (this information must be received on letterhead)
3. Patient will be asked to sign a statement to certify present situation.