Northland Cares Application
Northland Health Centers is a Federally Qualified Health Center and can offer reduced fees for Northland services. If you feel this may be a benefit to you and your family, please complete this application and attach income verification as defined below.
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Address
*
Address
City
State
Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
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Do NOT text me with questions.
Additional Household Members
Fill out the information below on every individual within your household that you would like listed on your Northland Cares Application
Additional Individual Name #1
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Male / Female
Relationship
Additional Individual Name #2
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Male / Female
Relationship
Additional Individual Name #3
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Male / Female
Relationship
Additional Individual Name #4
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Male / Female
Relationship
Additional Individual Name #5
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Male / Female
Relationship
Additional Individual Name #6
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Male / Female
Relationship
Additional Individual Name #7
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Male / Female
Relationship
Proof of Income is Required
Please upload proof of income for all household members.
Acceptable forms of income include but are not limited to the following:
Current Income Tax Document (Form 1040 and Schedule 1) (W2 or 1099 are also acceptable) --- Two consecutive (back-to-back) paystubs --- Social Security benefit letter --- Unemployment benefit letter or statement
File Upload
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Signature Required
Please sign and date with today's date
Applicant Signature
*
Today's Date
*
-
Month
-
Day
Year
Today's Date
Preview PDF
Submit
FOR NORTHLAND HEALTH CENTER STAFF ONLY
Total Income
Slide Level
Effective Date
-
Month
-
Day
Year
Expiration Date
-
Month
-
Day
Year
Should be Empty: