To be considered or remain a patient at the Beach Health Clinic, the following information must be provided prior to or on your next visit. If this information is not provided, you will be considered non-compliant and ruled ineligible for future services at the Beach Health Clinic.

A. PHOTO IDENTIFICATION

B. PROOF OF RESIDENCY:
We ask that you present any letter, bill or statement showing your name and current address.

C. PROOF OF HOUSEHOLD INCOME: (include spouse)
The following are acceptable as income verification: -Copies of recent, consecutive pay-stubs (equivalent of 1 month of work) or a letter from you employer verifying wages, ledgers or contract agreements. -Bank account statement(s) -Records of tips, bonuses, commissions. -Award letters or notices for Social Security (SSI, Survivors Benefits, Disability) Unemployment, Alimony, Child Support, Retirement, Pension, Food Stamps

D. W-2 FORM(S) and FEDERAL TAX RETURN
(ie. FORM 1040, 1099).

E. ASSISTANCE VERIFICATION LETTER W/ FINANCIAL DOCUMENTS This letter can be a typed or handwritten letter originated by the individual(s) who is providing financial assistance to you. The letter must be signed and dated. Financial documentation for the letter writer must be included for verification.

The Beach Health Clinic is able to treat patients because of donated time, talent, resources and services. It is extremely important that we are confident that the people being served are those for whom the services are intended.

Please know that with any false or withheld information, that services will be discontinued and patients will be responsible for bills incurred while enrolled in the clinic. For any questions or inquiries, please call the office at 428-5601.