Community Health Assistance Program (CHAP) Form

The following application is optional.

SICHC recommends filling it out, just in case you think you may be eligible.
However, if you choose to not enroll in CHAP, then proceed onto our final form —
Proof of Identity and Insurance.

About CHAP

Since 1975, Southern Indiana Community Health Care has offered financial assistance to anyone who is having difficulty paying for healthcare, and as a federally qualified community health center, we will not deny services to anyone based on their ability to pay.

SICHC’s Community Health Assistance Program (CHAP) offers a sliding fee discount for qualifying patients whose income and family size is below 200% of the federal poverty guidelines.

CHAP Benefits

Discount for office visits at any SICHC location including a school-based health center or a school-based telehealth visit.
Discount for lab services
Eligible for paid transportation vouchers from Blue River Transit Services and Orange County Transit to any SICHC location
More than Money Program – trade volunteer hours in the community for $15 toward any SICHC charges

If you have any questions, please contact Patient Accounts at (812) 723-7121.

Once this application is submitted, a representative from SICHC will contact you to help you submit additional needed forms.

Sliding Fee Discount Guidelines

Click on the link to see additional discount guidelines for Dental and Hospital Services

CHAP Application

Patient Name(Required)

First Last

Guarantor Name (if patient is a minor)(Required)

First Last

Patient's Date of Birth(Required)

List of family members who are included in your household. For each person, please include their:(Required)

Name

Relationship to Patient

Social Security Number

Date of Birth

Is this person an established patient with SICHC?

Does this person have an income?

Does this person have Insurance?

Family is defined as an individual or a group of two people or more related by birth, adoption, marriage and residing together. | Note - Click on the plus "+" icon to the right to add an additional household member.

Is anyone listed in this application pregnant?

Yes

Has the patient applied for insurance/Medicaid in the past 30 days?

Yes

If yes, on what date was the insurance/Medicaid applied for?

CHAP Agreement

A copy of the most recent federal income tax return supporting the income for the individuals listed above to the SICHC Paoli Office will need to be submitted. If a federal income tax return is not available or you are not required to file a tax return, please complete the Patient Self Declaration of Income Form located below.

You will have 30 days to provide all the required information/documentation. If you do not provide ALL of the information/documents, the CHAP Application will be DENIED. This means that the applicant and all household members will pay in full, until the required information/documents are received and a new CHAP application is completed.

I certify the information shown above is accurate and true. I understand that if I have provided false information, my account will default to the full amount due for services rendered. I also understand that this application is valid for one year, after which time, I will be asked to update my information.

Name(Required)

My name typed into the answer space to this statement serves as my electronic signature.

Date(Required)

Email(Required)

Phone(Required)

Patient Self Declaration of Income Form

Please provide the annual income for all family members over 19 years of age who are listed in section 2 ONLY if a federal income tax return is not available.

In addition, please mail the following documentation to the SICHC Paoli office:
SICHC Paoli
PO Box 270
Paoli IN, 47454

– Pay check stubs to support the wages shown above (clear copies of these documents are also acceptable).
– Support for any social security, pension and annuity income.

Name each family member listed above and include their annual income for each of the following categories:(Required)

Name

Income

Category*

Note - Click on the plus "+" icon to the right to add a new family member.

*Categories
• Wages and tips
• Self employment
• Unemployment
• Workers compensation
• Social security
• Veteran payments
• Child support and alimony
• Rental income
• Pensions and annuities
• Interest and dividends
• Other income

If a family member has income from multiple categories, please list on separate line.

Financial Position Declaration

I declare that the income information above is correct and accurately reflects my financial position. I am aware that providing false information will result in all discounts within the sliding fee discount program being revoked and the full balance of the accounts restored.