Membership Qualification | City Light Direct Primary Care

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Indicate how often each statement reflects your situation over the past 12 months.

(Consider healthcare needs and expenses for you and anyone you are financially responsible for, such as children or dependents.)

Membership Qualification Assessment

My monthly income was unpredictable. *

Rarely / Never

Sometimes

Often

Paying for healthcare required tradeoffs with other essential expenses such as food and housing. *

Rarely / Never

Sometimes

Often

My primary income came from part-time, seasonal, or contract work. *

Rarely / Never

Sometimes

Often

I delayed or skipped medical care I believed was needed because of cost. *

Rarely / Never

Sometimes

Often

I avoided routine doctor visits due to insurance deductibles or out-of-pocket costs. *

Rarely / Never

Sometimes

Often

I used urgent care or the emergency department for non-emergency concerns because I lacked affordable access to primary care. *

Rarely / Never

Sometimes

Often

An unexpected medical bill caused significant financial strain for my household. *

Rarely / Never

Sometimes

Often

I had difficulty paying for housing or utilities. *

Rarely / Never

Sometimes

Often

I affirm that my responses accurately reflect my current financial situation and that I am requesting evaluation for a reduced-rate membership due to ongoing financial constraint. I understand this program is offered in good faith to preserve access for those who need it.

RESULT TEXT

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123-456-7890

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Chesterfield County, VA, USA