ID & Income/Ingresos

ID and Income Submission

Health Brigade Registration
Name

First NameMiddle NameLast Name
Patient's Name (If different from above)

First NameMiddle NameLast Name
Patient's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Which of the following describes your insurance status?

Do you need to upload your Medicaid card?
Upload your Medicaid Card

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Do you need to upload your proof of income? (see examples below)
You may upload any of these documents as proof of income:
- Pay Stubs or W-2's
- Tax Returns
- Letter of Employment
- Letter of Benefits from Social Services or Social Security Administration
- Unemployment Benefits
- Letter of Support
- Child Support/Alimony/Spousal Support
Upload your Income Documentation

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Self-Declaration of Income
Complete the information below only if you have no other way to document your income. Check the box that best describes your current situation.

What is your average gross income?
How often do you get paid?
Employer Name
Type of Work
I certify that I have no other means of documenting my income and that all the information above is true and accurate.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Have you already submitted your photo ID?
Upload your photo ID

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Letter of Support
You mentioned you were receiving assistance or support from someone else. Would you like to download the Letter of Support form to have it notarized? If so, you can download it here. Otherwise, proceed to the next page.

You're almost finished!
Please make sure you have submitted/uploaded all the required documents before you press submit.
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