Patient Eligibility Screening Survey

Question 1: Verification

Are you 18 years of age or older?

Are you 18 years of age or older?(Required)

YES

NO

We’re sorry – PMCM provides care for adults (18 and older) at this time.

Question 2: Insurance Verification

Do you currently have any form of medical insurance?

(This includes Medicare, Medicaid, Affordable Care Act marketplace plans, or private insurance.)

Do you currently have any form of medical insurance?(Required)

Yes

No

We’re sorry – PMCMC provides care for uninsured adults only.

Question 3: Income Verification

How many people live in your household?

(Include yourself, your spouse or partner, and any dependents.)

How many people live in your household?(Required)

What is your household’s annual gross income?

Annual Income(Required)

Eligibility Guidelines

To qualify for services at PMCM, your household income must be at or below 300% of the Federal Poverty level (FPL) based on household size. (below chart subject to annual updates).

Household Income

$46,950
$63,550
$80,150
$96,750
$113,350
$129,950
$146,550
$163,150
$179,750

Household Size

1
2
3
4
5
6
7
8
9

Automated Screening Logic for web designer If user’s income is greater or equal to the corresponding 300% FPL threshold, display: • You may be eligible for care at Presbyterian Medical Care Mission. Please contact our office to complete registration. If the user’s household income is greater than FPL, display • Based on your responses, your household income exceeds our eligibility guidelines. If you need help finding affordable care options, please contact us for community referrals.

Patient Eligibility Screening Survey