Chesterfield Health District Service Eligibility Information

Eligibility requirements vary depending on the service provided. Some services are free, some are a flat fee and others have a fee based on a sliding scale. Sliding scale means that the fee is relative to your income. Financial eligibility is determined annually and whenever there is a change in financial status. You must have identification and proof of income when services are provided.

Proof of Income

• Pay Stubs - provide either the most recent with "Year to date" income listed, or 3 most recent
• W-2 Form or income tax return for most current calendar year
• Employer's written statement regarding weekly, monthly, or yearly gross income
• Unemployment notice from VEC (Virginia Employment Commission)
• Letter of Termination/Layoff notice from previous employer
• Statement of Social Security benefits or other benefits
• Military LES (leave and earning statement) (WIC Program Only)
• Foster care statement from Social Services
• Food stamps - Letter of eligibility (WIC Program Only)
• TANF (WIC Program Only)
• Medicaid card for current month
• Free or reduced school lunch - letter of eligibility (WIC and Dental Programs Only)
• Minors if not working must provide parents income to determine eligibility (WIC Program Only)
• Must have proof of residency (WIC, Child Health and Maternity)
• Must have proof of Identification (WIC Program Only)
• Medicaid HMO Card (WIC Program Only)

Proof of Identity

• Medicaid Card/HMO Card for each person being certified
• Driver's License
• Birth Certificate or Crib Card
• Social Security Card
  

Proof of Virginia Residence

• Medicaid Card/HMO Card for each person being certified
• Driver's License
• Rent/Mortgage Receipts

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Please bring Shot Records if you have them.

We accept Medicaid HMO's for :

• Family Planning
• Maternity - Virginia Premier or Sentara Family Care
  

 

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