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MATERNITY ELIGIBILITY ELIGIBILITY DOCUMENTS WILL BE ACCEPTED BY APPOINTMENT ONLY. YOUR APPOINTMENT WILL BE AT LOUDOUN COUNTY HEALTH DEPARTMENT 102 HERITAGE WAY, N.E. SUITE # 100 LEESBURG, VA 20176 PLEASE CALL [PHONE REDACTED] TO SCHEDULE AN APPOINTMENT **PATIENTS WITH PRIVATE HEALTH INSURANCE DO NOT QUALIFY FOR OUR PROGRAM** In order to start this process we need a posiƟve pregnancy test document, issued by a healthcare Provider staƟng your weeks of pregnancy OR first day of last menstrual period and delivery date. If you already have this proof of pregnancy, call and schedule a maternity eligibility appointment. If you do not have it, call and schedule a pregnancy test appointment. In order to proceed with the Maternity Eligibility process you must present: • Registration forms filled out in this packet. • ID: picture, name and date of birth: Driver’s license / State ID, Passport, Foreign country ID or Green card • Proof of Pregnancy: issued by a healthcare Provider stating your weeks of pregnancy OR first day of last menstrual period and delivery date. • Proof of address (2 documents) • Current Medicaid Card or Proof of Income (2 documents) Income Documentation Proof of Family Income - Spouse or Domestic Partner income is needed Must include at least two of the following documents: Proof of address / Residency Documentation with Applicant’s Name and Current Address Must include at least two of the following documents: Four Recent Paystubs Valid Virginia Issued Driver License or Identification Card Notarized Verification of Employment (Form/Letter completed By Employer) Notarized Verification of Residency (Form/Letter completed by Landlord) Most Recent Federal Income Tax Return (**Instructions Below**) Most Recent Federal Income/State Income Tax Return (**Instructions Below**) Bank Statement with Applicant’s Name and Current Address (Must be issued by a bank within the last 90 days reflecting deposits) Bank Statement (Must be issued at least 90 Days prior to date of service) Notarized Verification of Support Lease Agreement Alimony/Child Support Documentation Current Auto Insurance Policy or Home Insurance Policy Bill Government Assistance Program/Public Assistance Benefit Letter Utility Bill (Gas, Electric, Sewer, Water, Cable etc.) (Must be issued at least 90 Days prior to Date of Service) Social Security Benefit Letter Virginia Voter Registration Card I20 Form (International Students) Receipt for personal property taxes or real estate taxes paid within the last year to the Commonwealth of Virginia or a Virginia locality Pension/Retirement Income Virginia Department of Education Certificate of Enrollment form Survivor Benefits Certified copy of school records/transcripts issued by a school accredited by a U.S. state jurisdiction or territory Unemployment Compensation DMV Records Interest Dividends/Royalties/Income from Estate/Trust Immigration Residency Certification Document Education/Tuition Assistance Documentation W2 Ambassador Status Verification on Embassy Letterhead Third-Party Income Verification (Home Lease, Purchase Application, Automobile Lease, Loan Application, etc.) Tax Return – When submitting taxes completed by a firm or business please submit full document with date and signature. When submitting self- prepared taxes, please submit full documentation signed and dated 102 Heritage Way, NE Suites 100 & 101 PO BOX 7400 Leesburg, VA 20177-7400 [PHONE REDACTED] phone [PHONE REDACTED] fax ---PAGE BREAK--- Today’s Date: CHS – GEN – 01 REV 07/2024 REGISTRATION GUARANTOR INFORMATION (PARENT OR LEGAL GUARDIAN OF CHILD) NAME (FIRST) (MIDDLE) (LAST) DATE OF BIRTH (MONTH) (DAY) (YEAR) GENDER IDENITY □ MALE □ FEMALE □ Other: SOCIAL SECURITY NUMBER MARITAL STATUS ADDRESS CITY STATE ZIP HOME PHONE CELL PHONE WORK PHONE COUNTRY OF ORIGIN PREFERRED LANGUAGE RACE □ White □ Black or African American □ Asian □ American Indian or Alaskan Native □ Hawaiian Native or Other Pacific Islander DO YOU HAVE PRIVATE HEALTH INSURANCE? □ YES □ NO DO YOU HAVE MEDICAID? □ YES □ NO HOUSEHOLD INFORMATION LIST ALL MEMBERS IN YOUR HOUSEHOLD – SPOUSE/PARTNER, CHILD(REN) OR LEGAL DEPENDENTS FULL NAME: GENDER IDENTITY: □ MALE (FIRST) (MIDDLE) (LAST) □ FEMALE □ OTHER DATE OF BIRTH: RELATIONSHIP TO YOU: RACE: □ White □ Black or African American □ Asian □American Indian or Alaskan Native □ Hawaiian Native or Other Pacific Islander DOES THIS PERSON HAVE: □ PRIVATE INSURANCE □ MEDICAID □ NO INSURANCE FULL NAME: GENDER IDENTITY: □ MALE (FIRST) (MIDDLE) (LAST) □ FEMALE □ OTHER DATE OF BIRTH: RELATIONSHIP TO YOU: RACE: □ White □ Black or African American □ Asian □American Indian or Alaskan Native □ Hawaiian Native or Other Pacific Islander DOES THIS PERSON HAVE: □ PRIVATE INSURANCE □ MEDICAID □ NO INSURANCE ---PAGE BREAK--- Today’s Date: CHS – GEN – 01 REV 07/2024 FULL NAME: GENDER IDENTITY: □ MALE (FIRST) (MIDDLE) (LAST) □ FEMALE □ OTHER DATE OF BIRTH: RELATIONSHIP TO YOU: RACE: □ White □ Black or African American □ Asian □American Indian or Alaskan Native □ Hawaiian Native or Other Pacific Islander DOES THIS PERSON HAVE: □ PRIVATE INSURANCE □ MEDICAID □ NO INSURANCE FULL NAME: GENDER IDENTITY: □ MALE (FIRST) (MIDDLE) (LAST) □ FEMALE □ OTHER DATE OF BIRTH: RELATIONSHIP TO YOU: RACE: □ White □ Black or African American □ Asian □American Indian or Alaskan Native □ Hawaiian Native or Other Pacific Islander DOES THIS PERSON HAVE: □ PRIVATE INSURANCE □ MEDICAID □ NO INSURANCE FULL NAME: GENDER IDENTITY: □ MALE (FIRST) (MIDDLE) (LAST) □ FEMALE □ OTHER DATE OF BIRTH: RELATIONSHIP TO YOU: RACE: □ White □ Black or African American □ Asian □American Indian or Alaskan Native □ Hawaiian Native or Other Pacific Islander DOES THIS PERSON HAVE: □ PRIVATE INSURANCE □ MEDICAID □ NO INSURANCE FULL NAME: GENDER IDENTITY: □ MALE (FIRST) (MIDDLE) (LAST) □ FEMALE □ OTHER DATE OF BIRTH: RELATIONSHIP TO YOU: RACE: □ White □ Black or African American □ Asian □American Indian or Alaskan Native □ Hawaiian Native or Other Pacific Islander DOES THIS PERSON HAVE: □ PRIVATE INSURANCE □ MEDICAID □ NO INSURANCE