RM_Stats

Verification of Earnings

Email^*

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Client Name

Client DOB

Effective Date

Date of First Visit

The following information is required for use in determining if services rendered by client are eligible to be covered through funding provided by the Indigent Health Care 1/2 cent sales surtax. Information will be used solely for this purpose. Eligibility determination for coverage under this funding does not approve or deny client to receive services at the facility. Please complete the below for any household member of the client needing verification of earnings (including client).

Employee Name

Employee Phone

Employee Address

Address Line 1

Address Line 2

City

State or Region

Country

Zip

Employer Name

Employer Phone

Employer Address

Address Line 1

Address Line 2

City

State or Region

Country

Zip

Date Employment Began

Date Employment Ended

If terminated, is it permanent or temporary?

Permanent
Temporary

Date Expected to Return

Gross Earnings

Please select one of the following options:

From selected date to selected date
From January 1st through current date
As reported on Employees W-2 statement for prior year

Gross Earnings Start Date

Gross Earnings End Date

Amount (in $USD)

Please enter your gross earnings in $USD for the selected date range.

Insurance Coverage

Is/Was employee covered by health insurance?

If yes, are/were any dependents covered?

Signature of Employer

Date

Name and Title of Employer Authorized Representative

I certify that the information provided in this form is accurate and true.

Signature of Client

Date

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Verification of Earnings

Gross Earnings

Insurance Coverage

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