Henrico Clinic Proof of Income
Services are provided on the State of Virginia Sliding Scale Fee Schedule
according to ability to pay. Proof of Income is required for all members who
share financial responsibility of the household (examples: husband/wife, boyfriend/girlfriend,
parent/children, relatives living together).
- A pay stub with year-to-date total. If year-to-date totals are not available,
you must bring three (3) check stubs for the past three consecutive pay
periods.
- A current year income tax form (must be signed by preparer and filed with
IRS).
- Self-employed: Must bring the income tax form and the Schedule C. You
may also bring ledgers that show business revenues and expenses.
- Statement from employer (only under extenuating situations will this apply).
Letter must be on company letter head, dated, signed by a company official,
and include the gross pay for the past three consecutive pay periods. Letter
will not be acepted unless it has this complete information.
- A signed letter from the Department of Social Services to determine eligibility.
- Unemployed: The only allowable verification is a statement from the Virginia
Employment Commission stateing the amount of benefits and the weeks remaining.
- Alimony/Child Support: A legal document (divorce papers, judgments, custody
papers, copies of checks, writen declaration) must be presented.
If you do not bring Proof of Income of if we are unable to verify your income,
you will be required to pay the full fee. Payment is required at the time of
your appointment so bring money or check with you. We need to be informed of
ANY medical insurance IMMEDIATELY.
