Better Care. Better Health. A Better Community.

Registration Information
LAST NAME
MI

FIRST NAME

DATE OF BIRTH

STREET ADDRESS

CITY

STATE

ZIP

TELEPHONE HOME

MAILING ADDRESS (if different from

above)

CITY

STATE

ZIP

TELEPHONE WORK

GENDER
M

MARITAL
STATUS:
Single
Married
Divorced
Separated
Widowed

NUMBER IN

SSN#

INTERPRETATION
NEEDED:

HOUSEHOLD:
DRIVER LIC/STATE ID#

YES
APPLICANTS EMPLOYMENT:
FULL TIME
WORK

STATE:

CELL PHONE #

NO

SEASONAL

PART TIME

RACE:
African American
Asian
Caucasian
Hispanic
Native American
Other

TEMPORARY
ETHNICITY:
OTHER:
UNEMPLOYED

Emergency Contact/Relationship:

PRIMARY
LANGUAGE:

Emergency Contact Phone#:

Housing & Employment (Work)

PLEASE LIST EVERYONE IN THE HOUSEHOLD. Please provide all wage-earners. YOU MUST INCLUDE GROSS (PRETAX)
WAGES, ALIMONY INCOME, RENTAL INCOME, UNEMPLOYMENT COMPENSATION, SOCIAL SECURITY BENEFITS,
PUBLIC /GOVT ASSISTANCE, ETC.
NAME
RELATIONSHIP TO
NAME OF EMPLOYER/SOURCE MONTHLY GROSS
PATIENT
OF INCOME
INCOME
1.
$
2.
$
Accurate Information and Duty to Supplication: The undersigned certifies that the information provided to
AccessHealth Greenville County (AHGC), as reflected on the AHGC Application, is accurate to the best of his/her
knowledge. The undersigned agrees that he/she shall immediately notify AHGC of any change in the information
provided. The undersigned understands the eligibility criteria and that any change in that eligibility criteria may
forfeit his/her participation in the AccessHealth Greenville County program.

Better Care. Better Health. A Better Community.

Eligibility and Agreement of Participation: The undersigned agrees that he/she understands the terms and
conditions of the AccessHealth Greenville County.
Financial Responsibility: The undersigned further understands he/she is financially responsible for services outside
of the AccessHealth Greenville County.
Participant Signature: _____________________________ Date: ____________________
For AHGC Staff Use Only
Referral for: (check all that apply)
Medical Home Apply for AHGC

Recertification

Specialty Care

AHGC Staff (please print): _______________________________________

Staff Signature: ___________________________________ Date:
_______________________________
Referral for: ________________________________ To:
_______________________________________
Referral for: ________________________________ To:
_______________________________________
for: ________________________________ To:
AHGCReferral
Qualifications*
_______________________________________
1) No insurance or eligibility for an insurance program (Medicaid, Medicare, Marketplace, employer, etc.)
2) Resident of Greenville County
3) Income at or below 200% FPL (100% guidelines below)
*HOP patients qualify for AHGC
2015 POVERTY GUIDELINES FOR THE 48 CONTIGUOUS
STATES
AND THE DISTRICT OF COLUMBIA
Persons in family/household

Poverty guideline

For families/households with more than 8 persons, add

$4,160 for each additional person.
1

$11,770

15,930

20,090

24,250

28,410

32,570

36,730

8
40,890
(http://aspe.hhs.gov/poverty/15poverty.cfm#thresholds)

Better Care. Better Health. A Better Community.

Patient Requirements and Responsibilities
The following are requirements for enrollment in AccessHealth Greenville County (AHGC). Please read and commit
to keeping your responsibilities.
1.

AHGC is a program. The participating doctors and physicians are donating or discounting your care. AHGC will
not pay for your care.

2.

AHGC is assisting you in coordinating care and attempting to locate the appropriate medical and/or social
provider for you, but it is not itself providing or furnishing medical services to you. You agree to see a doctor
within 2 months of enrollment.

3.

AHGC reserves the right to disenroll you from the program for any reports of discourtesy, abusive language or
threats (please thank your providers for participating in AHGC).

4.

Being enrolled in AHGC does NOT provide you with health insurance. AHGC is NOT health insurance. AHGC
is not a government program like Medicare or Medicaid. Any use of your AHGC card must be approved. You
will be responsible for any charges for appointments not approved through AHGC.

5.

You must keep all scheduled appointments with the understanding that more than two missed appointments
without providing notice at least 24-hours in advance will result in automatic dismissal from the program.

6.

If you schedule an appointment with a healthcare provider not involved with AHGC or if go to the emergency
room (ER) you will be responsible for the bill. Any use of your AHGC card must be approved. Before going to
any appointment (lab work, xrays, another appointment scheduled by your doctor) always call AHGC for
approval even if it is for a follow-up appointment.

7.

You are not eligible for AHGC privileges if you have access to health insurance. Immediately contact AHGC if
you become enrolled in Medicare, Medicaid, private insurance or any other medical coverage plan (including
through spouse, parent, etc.) or if you become qualified for these programs.

8.

If you have any legal action pending regarding your medical needs, you must notify AHGC immediately.
Failure to disclose this information will result in immediate dismissal from the program and you will be
responsible for all medical bills incurred.

9.

Reenrollment is available for medical conditions that require ongoing care beyond the enrollment period.
Every applicant must reapply for continued care when the enrollment period expires. It is your responsibility
to schedule an appointment with AHGC to reenroll if needed.

10. You are required to immediately contact AHGC if your household income or physical address changes. Failure
to do so could result in you becoming disenrolled from the program.
11. Enrollment with AHGC does not guarantee assistance with every need or request.
12. Some procedures ordered by your physician may not be available through AHGC. You will be financially
responsible for any treatments, procedures, tests or services not available through the AHGC program. It is
your responsibility to discuss any additional services being provided with the office staff to determine if you
will be responsible for any charges.

Better Care. Better Health. A Better Community.

POSSIBLE EXAMPLES:
Cardiology studies such as a stress test or stress echo are provided at no charge through the AHGC
program but the cardiologist fee for reading the test is a separate charge and not covered through AHGC.

A surgeon may donate his services to do a biopsy but the pathologist fee to process the biopsy is a
separate fee and not covered through AHGC.

Xrays are available to AHGC participants at no charge but the prep kit required for some xrays are not
provided

13. AHGC is not able to assist with urgent or emergent needs. Some requests to see a specialist have a waiting list
of up to three months or more. You can see a specialist without going through the AHGC program. If you feel
you need to see a specialist quickly contact your doctors office to assist you with an appointment. You will be
responsible for all bills if you choose to see a specialist on your own.

14. You will not request pain medication or other controlled substances from AHGC providers.

15. You will NOT to present disability forms to AHGC providers, or request tests/procedures designed to prove
disability. Treatment by AHGC providers is designed to manage and improve your health.

I have read the above and agree to comply with all requirements for participation. I further agree to provide
truthful and accurate information regarding my financial, health and employment status. I understand if I
withhold information or provide false information I will immediately be disqualified from participation in this
program.
____________________________________________________________________________________
Signature of Applicant
Date

____________________________________________________________________________________
Signature of Staff
Date

Better Care. Better Health. A Better Community.

Appointment Information
Date:

Dear_______________________,
Welcome to AccessHealth Greenville County!
A medical home appointment for primary care has been made for you. If you cannot make this appointment time,
please contact the medical home at least 24 hours prior to your appointment and contact your care transition
coordinator at (864) ___-_______.
You have agreed to see a medical home physician within 2 months of registration with AccessHealth Greenville
County. Please expect to provide your AHGC card to the front office staff at your appointment.
Appointment details

Appointment date:

_________________________

Appointment time: ____________

Medical Home: _________________________________________________

Phone number: _________________________________________________

Address:
________________________________________________

________________________________________________