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Schedule I
(Form 990)
Department of the Treasury
Internal Revenue Service
Grants and Other Assistance to Organizations,
Governments and Individuals in the United States
Complete if the organization answered "Yes," on Form 990, Part IV, line 21 or 22.
lBullet Attach to Form 990.
lBullet Go to www.irs.gov/Form990 for the latest information.
OMB No. 1545-0047
2020
Open to Public
Inspection
Name of the organization
THE NORTHERN NECK-MIDDLESEX
FREE HEALTH CLINIC INC
Employer identification number
54-1679279
Part I
General Information on Grants and Assistance
1
Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and
the selection criteria used to award the grants or assistance? ........................
2
Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.
Part II
Grants and Other Assistance to Domestic Organizations and Domestic Governments. Complete if the organization answered "Yes" on Form 990, Part IV, line 21, for any recipient
that received more than $5,000. Part II can be duplicated if additional space is needed.
(a) Name and address of organization
or government
(b) EIN (c) IRC section
(if applicable)
(d) Amount of cash grant (e) Amount of non-cash
assistance
(f) Method of valuation
(book, FMV, appraisal,
other)
(g) Description of
noncash assistance
(h) Purpose of grant
or assistance
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
2
Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................. Bullet Image
 
3
Enter total number of other organizations listed in the line 1 table ........................ . Bullet Image
 
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50055P
Schedule I (Form 990) 2020
Page 2

Schedule I (Form 990) 2020
Page 2
Part III
Grants and Other Assistance to Domestic Individuals. Complete if the organization answered "Yes" on Form 990, Part IV, line 22.
Part III can be duplicated if additional space is needed.
(a) Type of grant or assistance (b) Number of
recipients
(c) Amount of
cash grant
(d) Amount of
noncash assistance
(e) Method of valuation (book,
FMV, appraisal, other)
(f) Description of noncash assistance
(1) PRESCRIPTION MEDICATIONS PROVIDED TO UNINSURED OR UNDERINSURED INDIVIDUALS IN THE NORTHERN NECK REGION AND MIDDLESEX COUNTY OF VIRGINIA 1628   1,781,504 FAIR MARKET VALUE PRESCRIPTION MEDICATIONS
(1)
(2)
(3)
(4)
(5)
(6)
(7)
Part IV
Supplemental Information. Provide the information required in Part I, line 2; Part III, column (b); and any other additional information.
Return Reference Explanation
PART I, LINE 2: PATIENT ELIGIBILITY IS DOCUMENTED PRIOR TO DISPENSING ANY MEDICATIONS. NNFHCP SCREENS PATIENTS USING ELIGIBILITY FORMS THAT HAVE BEEN APPROVED BY MANAGEMENT. THE FORMS DECLARATION OF INCOME/ NO INCOME AND NO LONGER WORKING ARE NEVER USED BY THEMSELVES TO DETERMINE ELIGIBILITY. THERE WILL ALWAYS BE OTHER DOCUMENTATION ALONG WITH THESE FORMS (FOR EXAMPLE: FOOD STAMP LETTER, SOCIAL SECURITY LETTER, LETTER OF SUPPORT). EACH PATIENT MUST BE SCREENED FOR ELIGIBILITY DETERMINATION EVERY 12 MONTHS, AT A MINIMUM, HAVE COMBINED HOUSEHOLD INCOME AT OR BELOW 250% OF FEDERAL POVERTY LEVEL FOR MEDICAL SERVICES AND 300% FOR DENTAL SERVICES, AND BE WITHOUT ANY PRESCRIPTION DRUG COVERAGE. VIRGINIA RESIDENCY IS REQUIRED FOR EACH PATIENT. AT A MINIMUM, ELIGIBILITY SCREENERS MUST REVIEW A PATIENT SIGNED ELIGIBILITY FORM, WHICH IDENTIFIES THE PATIENT'S VIRGINIA ADDRESS. LASTLY, PATIENTS MUST ATTEST TO THE FACT THEY HAVE NO INSURANCE ON A SIGNED ELIGIBILITY FORM.
Schedule I (Form 990) 2020



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