Eligibility to receive Services

To receive services, a person must meet two criteria:

  1. No health insurance – no Medicare, Medicaid, VA, or private health insurance
  2. Household income at or below 175% of the Federal Poverty Level

           The 2018 Federal Poverty Level is defined as:

  • $1,770/month or $21,245/year – 1 person
  • $2,400/month or $28,805/year – 2 people
  • $2,030/month or $36,365/year – 3 people
  • $3,550/month or $43,925/year – 4 people

What Do i need to Bring?

If you do not have your complete financial 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 all documentation is received. You will not be permitted to see the provider after that time until all your documentation is received. Documentation will be accepted Monday – Thursday from 8-4 and Friday from 8-11.

Updates to the Verification of No Income Status form and paystubs will be completed every 6 months.

Patient Identification

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

Social Security

  • Social Security Number/Card

Proof of Household Income

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

  • Most recent federal tax return AND W-2 (Form 1040, 1040A, 1040EZ, 1099)
  • Medicaid Denial Letter - you will have 60 days to bring in the denial letter from the date of 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 each for other working adults (18 years old and above) living in household.

Unemployed

  • IRS 4506-T for patients who do not file a Federal tax return
  • Medicaid Denial Letter - you will have 60 days to bring in the denial letter from the date of your visit