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News
Updated Patient Guidelines
July 26, 2017
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Due to changing demands from pharmaceutical companies who donate medications to the Clinic, we have updated information that current and potential patients will need to provide for their visit, effective immediately.

If you do not have your complete information, you will be permitted to see the provider for that visit, but no medications from the on-site pharmacy or specialist referrals will be provided until that documentation is received. You will not be permitted to see the provider after that time until all your documentation is received.

Updates to the Verification of No Income Status form and paystubs will be completed every 6 months. Please bring in any additional required information before 4 pm.

Please complete and print any forms linked below and bring with you to your visit.

Patient Identification
Picture ID: drivers license, visa, passport, or other state issued
Proof of Residence: current utility bill, tax bill, lease, etc.

Social Security
Social Security Number
No Social Security Number Declaration Form

Proof of Household Income

Employed or receiving an income (Social Security, SSI disability, workman’s comp, or retirement income, etc.)

  • Most recent federal tax return or W-2 (Form 1040, 1040A, 1040EZ, 1099)
  • Medicaid Denial Letter (you will have 4 months to bring in the denial letter from your visit)
  • Proof (i.e. award letter or agency statement) of Social Security, SSI disability, workman’s comp, or retirement income for patient and all adults (18 years old and above) living in household.
  • Most recent 3 paystubs for patient and 1 paystub for other working adults (18 years old and above) living in household.
  • Self employed Verification Form (if applicable)
  • Support by Family or Friend Verification Form (if receiving any support – housing or financial)

Unemployed 

  • IRS 4506-T (patients who do not file a Federal tax return)
  • Medicaid Denial Letter (you will have 4 months to bring in the denial letter from the date of your visit)
  • Proof of Unemployment for patient and all adults (18 years old and above) living in household. Please log into your SCDEW account, if unemployed, and print off your statement and bring with you.
  • Current FAP, Palmetto AccessHealth, and/or other outside financial program card/documentation (if applicable)
  • Support by Family or Friend Verification Form (if receiving any support – housing or financial)

Claiming a Patient Slot
Patient slots are limited and vary on a daily basis. Please arrive early enough to claim a slot for the day – most patients arrive by 7 am. If you are given an afternoon slot, you will be allowed to leave and come back after the Clinic’s lunch break for your slot.