Application for Primary Care Benefits 

Look at the Completed Sample Application for Primary Care Benefits.

  1. Hand the patient a CAP brochure, explain its purpose and the eligibility criteria:
a) Federal Poverty Level (FPL) at or below 200%,
  b) Enrollee is 18 or more years of age and less than 65 years of age, and
c) Enrollee is not insured & not eligible for insurance (i.e., Medicaid, Medicare).
  1. Complete or update your organization's Sliding Fee Application to determine the current total household size and total monthly household income and thereby the FPL.

  2. If the patient meets the eligibility criteria in a, b and c, enter the Enrollee name (First, Middle Initial and Last) and the Social Security Number onto the CAP Application for Primary Care Benefits as shown in the completed sample.

  3. Ask the CAP enrollee to read, sign and date the Enrollment, Authorization or Release portion of this Application.
    4.  

  4. Witness this signature by signing and dating the form yourself. 

  5. Check the form for completeness and legibility.

  6. Store the completed form in accordance with the policies of your organization.

  7. The Application form is available in Microsoft Word format.  Add  your corporation's name at the top of the Application form, before you make copies.

  8. Complete the Patient Financial Statement. Instructions have been previously provided.

  9. Have the CAP Enrollee complete the Health History scan form (click for instructions).

  10. Issue a membership card to the new CAP Enrollee by writing in the CAP Enrollee's name.

  11. On the back of the card, check the block Clinic "Eligible for SF (Sliding Fee) Yes or No and write in the FPL determined by completing the Sliding Fee Application.

  12. Check the block " Hospital Eligibility" either Yes or No.  If the Patient Financial Statement indicates that the CAP Enrollee is eligible, the correct response is "Y" for Yes.
    13. Write in the FPL you determined by completing the Patient Financial Statement.

  13. Examine your work, laminate the CAP membership card and present it to the CAP Enrollee.

  14. Use the CAP Data Entry web site to enter the Enrollment and  Health History data (alternatively send the completed CAP Health History scan form to the CAP IS Coordinator).

          You have completed the CAP Enrollment process!