SJRMC Quick Screen - The Midland Group

How many people are in your household? *

Is your household gross income less than $2,430 per month? *

Yes
No
Declined to answer

Is your household gross income less than $3,287 per month? *

Yes
No

Is your household gross income less than $4,143 per month? *

Yes
No

Is your household gross income less than $5,000 per month? *

Yes
No

Is your household gross income less than $5,857 per month? *

Yes
No

Is your household gross income less than $6,713 per month? *

Yes
No

Is your household gross income less than $7,570 per month? *

Yes
No

Is your household gross income less than $8,427 per month? *

Yes
No

Is your household gross income less than $9,283 per month? *

Yes
No

Is your household gross income less than $10,140 per month? *

Yes
No

Is your household gross income less than $10,997 per month? *

Yes
No

Is your household gross income less than $11,853 per month? *

Yes
No

Is your household gross income less than $12,710 per month? *

Yes
No

Is your household gross income less than $13,567 per month? *

Yes
No

Have you received or will you be receiving services at San Juan Regional Medical Center or one of their facilities? *

Are you a resident of New Mexico? *

Are you Native American? *

Have you notified IHS of your visit? *

Are you a Veteran? *

Are you the victim of a crime which resulted in this hospital visit? *

Was your visit due to an accident or injury? *

Are you pregnant? *

Are you 65 years of age or older? *

Patient Refused Screening *

Yes
No

Encounter Number

Name *

First

Last

Do you have a contact phone number? *

Yes
No

Phone *

Email

Phone

505-609-6006

Visit

midland group Office
801 W. Maple St.

Farmington, NM 87401

Phone

505-609-6006

Visit

midland group Office 801 W. Maple St. Farmington, NM 87401

midland group Office
801 W. Maple St.

Farmington, NM 87401