Clinic by the Bay Eligibility Screening Form
Full Name
First Name
Last Name
Birth Date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
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31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
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1931
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1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Gender
*
Home Address
*
City
ZIP Code
How long have you lived at this address?
Who is part of your household?
Click to edit
Click to edit
Who is part of your household?
Eligibility Verification
Please Select
Calif. ID
Current Utility Bill
Rent Receipt,Lease,Mortgage
Other
Primary Phone Number
*
-
Area Code
Phone Number
E-mail
Length of Time at Current Address
Please Select
Less than 30 days
More than 30 days
Best way to contact you?
Please Select
Phone
Email
U.S. Mail
Country of Birth
Primary Language
Please Select
English
Spanish
Tagalog
Mandarin
Cantonese
Other
Marital Status
Please Select
Married
Single
Domestic Partner
Medical Insurance
Please Select
Private
Medicare A
Medicare B
Medi-Cal
Veterans Benefits
Healthy Families Program
Other
Other Provider (specify)
Other program?
Please Select
Healthy SF
ACE - San Mateo County
Dental Insurance?
Please Select
Yes
No
Currently employed?
Please Select
Yes
No
Name of Employer
Employer Address
Employer Phone #
Gross Income Monthly b4 Tax
*
Other Income source
Please Select
Unemployment Insurance
Disability Insurance
Child Support/Spousal Support
Self-Employed
Other (specify)
# of people in Household
*
Names of Household Members
*
Submit Form
For Referral Agency Only
Referral Agency
Contact Person
Contact Phone #
Contact Email
Other Info
Submit Form
For Clinic Use Only
CBTB Eligible
*
Please Select
Yes
No
Pending
Address Verification
Please Select
Lease/Mortgage
Utility Bill
Other
Interviewer Name
*
Interviewer Comments
Click to edit
Submit Form
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