Patient Applications

 
To become a patient at the River Valley Christian Clinic you must complete the following eight forms.
 

    Attention:

The following forms are in .PDF format for Adobe Reader.  The files can be large and take a while to load if you are using a dial-up modem.  Because of the size of the .PDF files it is best to open each file, print it, close it before opening the next file.  You must have Adobe Reader on the computer you are using to access these files. 
 
1. Cover Sheet: Contains a check list of all information required to apply for River Valley Christian Clinic eligibility. Required.
     
2. Personal Information Patient personal information.  Required.
     
3. Monthly Income All household income amounts.  Required.
     
4. Monthly Expenses Approx. monthly expenses.  Required.
     
5. Medical Insurance Information on patient medical insurance.  Required.
     
6. Non-Permanent Employment To identify patient with part-time, non-permanent employment.  Required.
     
7. Family / Friend Assistance To identify aid patient gains from family or friends. Required.
     
8. Federal 1040 Form or
4506-T Form
Form 1040 for the current year if you filed or fill out the Form 4506-T if you did not file.  Required.
 
When you have completed the application and have the documentation for everyone in your home who has income, call and make an appointment for your interview.