Connecticut Institute For Communities, Inc.

d/b/a

Greater Danbury Community Health Center

57 North Street, Suite 311 Danbury, CT 06810 Dr. Thomas F. Draper, M.D., MPH Medical Director THE GREATER DANBURY COMMUNITY HEALTH CENTERS MOBILE HEALTH VAN IS COMING TO DANBURY HIGH SCHOOL TO PROVIDE SPORTS PHYSICALS! June 15, 2013 Dear Parent or Guardian: On August 14, 2013, Connecticut Institute For Communities, Inc.s non-profit Greater Danbury Community Health Center (GDCHC) Mobile Health Van , will be at Danbury High School to offer sports physicals to Danbury students from 1-4pm. WHAT IS THE CIFC GREATER DANBURY COMMUNITY HEALTH CENTER? The CIFC Greater Danbury Community Health Center is a non-profit Federally Qualified Health Center located at 57 North Street in Danbury, Connecticut. The mission of the CIFC Greater Danbury Community Health Center is to ensure affordable, accessible, comprehensive, high quality health care to the residents of the Greater Danbury area, regardless of their ability to pay or their insurance status. The CIFC Greater Danbury Community Health Center offers a comprehensive range of outpatient primary care, including medical, dental and mental health services, on a sliding fee basis, to people of all ages: children, adolescents, adults and seniors. WHAT IS THE CIFC GREATER DANBURY COMMUNITY HEALTH CENTER MOBILE HEALTH VAN? In addition to its main location at 57 North Street, the CIFC Greater Danbury Community Health Center offers services through a mobile health van, which travels throughout the Greater Danbury Community Health Centers ten town service area. Given the expressed need for sports physicals in Danbury, the Greater Danbury Community Health Center will be at Danbury High School on August 14, 2013 to offer a convenient way for your children to obtain sports physicals. INTAKE AND CONSENT FORMS FOR SPORTS PHYSICALS In order for students to obtain sports physicals on the mobile health van, parental or guardian permission is required. You must complete intake and consent forms for your child. We encourage you to complete these forms in advance. You may obtain electronic copies of the intake and consent forms by contacting Ms. Kaitlin Carney at CarneyK@ct-institute.org. These forms will also be available on site and may be completed on the day of service. Finally, we also encourage you to schedule an appointment in advance by contacting Ms. Kaitlin Carney at CarneyK@ct-institute.org or (203) 743-0100 x 345.

Business office 7 Old Sherman Turnpike, Suite 212 Danbury, CT 06810

Phone: (203) 743-9760 Fax: (203) 743-3411

Patient Services 57 North Street, Suites 309-311 Danbury, CT 06810

Phone: (203) 743-4168 Fax: (203) 743-794-1851

Email: info@CT-Institute.org

SLIDING FEE SCALE Our Health Center may be able to provide financial assistance to help you pay for your childs sports physical. Eligibility for financial assistance is based on whether you fall within the following income limits:
Number of Household Members 1 2 3 4 Total Annual Household Income $22,980 or less $31,020 or less $39,060 or less $47,100 or less Number of Household Members 5 6 7 For family units of 8 or more members, add $4020.00 for each member. Total Annual Household Income $55,140 or less $63,180 or less $71,220 or less

If you believe that you fall within the above chart, please provide a copy of ONE of the following on the day of service: - 2 current consecutive pay stubs; OR Spend Down letter from the Department of Social Services; OR Letter from employer on Employer Letterhead stating the employees hours and days worked and amount earned weekly; OR If self employed, a letter stating so with the hours and days worked and amount earned weekly; OR Social Security disability income statement; OR Unemployment income statement; OR If a students parent(s) or guardian(s) is/are unemployed without benefits or self employed, the parent/guardian can sign a statement indicating such and stating total family income and mail that back with the enrollment forms.

Based on the information provided, you may be charged a flat fee of $20 on the day of your visit or $0 if you have no income. INSURANCE AND PAYMENTS If you have health insurance, you will be required to provide your health insurance information on the intake form. We will then bill your insurance and collect co-payments on the day of service. If you have any questions about the mobile health van or the Greater Danbury Community Health Center, please feel free to contact Ms. Kaitlin Carney at (203) 743-0100 x345 Yours truly,

Dr. Thomas F. Draper, MD, MPH Medical Director P.S. If your child needs an annual physical, immunizations or has other medical needs that you would like to address, you may schedule an appointment at our main office at 57 North Street, Danbury, CT.

We are also pleased to accept all patients there, including parents, adults and other family members (also on our sliding fee scale). If you would like to make an appointment at our main office, including during evenings and Saturdays, please call (203) 743-0100 x 342.