Clinic by the Bay Eligibility Screening Form
Full Name
First Name
Last Name
Birth Date
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
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4
5
6
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22
23
24
25
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27
28
29
30
31
Day
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
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
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
Less than 30 days
More than 30 days
Best way to contact you?
Phone
Email
U.S. Mail
Country of Birth
Primary Language
English
Spanish
Tagalog
Mandarin
Cantonese
Other
Marital Status
Married
Single
Domestic Partner
Medical Insurance
Private
Medicare A
Medicare B
Medi-Cal
Veterans Benefits
Healthy Families Program
Other
Other Provider (specify)
Other program?
Healthy SF
ACE - San Mateo County
Dental Insurance?
Yes
No
Currently employed?
Yes
No
Name of Employer
Employer Address
Employer Phone #
Gross Income Monthly b4 Tax
*
Other Income source
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
*
Yes
No
Pending
Address Verification
Lease/Mortgage
Utility Bill
Other
Interviewer Name
*
Interviewer Comments
Click to edit
Submit Form
Should be Empty: