Welcome to QueensCare Health Centers!
From your conversation with our Health Advocates, families need to submit various documents when applying for healthcare programs. We will not be able to enroll or renew your coverage without the proper documentation. If you have any questions regarding document requirements, please contact us at (323) 635-1140.
The following list describes the main types of documents that may be needed:
Proof of Income: Required for all health programs.
Some examples of proof of income:
- Paycheck: Most current paycheck stub (no more than 45 days old). You may need to provide more than one paystub depending on the frequency of the payment:
- Weekly payment (4 paystubs required)
- Every two weeks (2 paystubs required)
- Monthly (1 paystub required)
- Federal Income Tax 1040 from previous year.
- Self-Employed Family Members: May submit their Federal 1040 or 1099 forms and Schedule C from the previous year or 3-month profit/loss statements for current year (please bring taxes current year).
- Cash or Personal Check Payments: Will need to bring a letter from an employer. Letter must include employer’s letterhead or the name, address, and phone number of the company.
- The letter must indicate the payment frequency (e.g. weekly, bimonthly, etc.) and the gross payment amount (indicate pay in cash).
- The letter must be signed and dated by the employer.
- Unemployment Benefits: Copy of award letter, copy of check or bank statement showing direct deposit.
- Proof of Disability Payments SSA or SSI: Copy of award letter, copy of check, or copy of bank statement showing direct deposit.
- In Kind Letter: Signed and dated letter from the person(s) providing support.
- Alimony/Child Support: Copy of payment receipt and copy of court order.
- Self-Affidavit: A sworn statement indicating the amount and frequency of pay. A self-affidavit can only be used when there is no other income documentation available. Check with specific programs for more information.
- Proof of Income for Families: Required for biological and adoptive parents.
- For Medi-Cal and Healthy Families: boyfriend/girlfriend should not be asked for proof of income unless he or she is applying for one of their own children or if the patient will apply for Medi-Cal separately.
- Stepparents income is not counted when applying for their stepchildren. However, the stepparents still count in the family size.
Proof of Citizenship or legal Residency.
- US Birth certificate (any country).
- US passport.
- Certificate of naturalization.
- Green card (front and back side).
- Work permit (front and back side).
- For applicants who have an approved family petition to become a legal resident, please bring I-797 immigration notice of action.
- Birth certificates for all Minors (mandatory).
Proof of Identify: Photo ID for all applying adults.
- ANY form of identification with name, photo, and date of birth.
- If applicable, social security card (needed for all family members within the application).
Proof of address: May provide a bill or statement.
- You may bring a utility bill such as a gas, cable, phone bill, insurance bill, etc. This statement/bill must be post stamped within 60 days.
Proof of all assets (for people over 65 or disabled).
- Recent bank statement, car registration, property titles, ETC.
- Medicare part A or B premium; Court order child support/ spousal support.
Other documents that may be required.
- Marriage certificate or a pregnancy test.