Apply for Help
Qualification is determined by medical and financial need. The Broad Street Clinic is a chronic care clinic treating the five chronic disease of diabetes, high blood pressure, heart and/or lung disease and thyroid disease. A patient’s eligibility determination must be renewed annually with their patient advocate.
Please bring in all of the requested information.
- If Employed: Bring in the following financial information
- Pay Stubs for the last three months for all household incomes
- Latest Federal Income Tax paperwork with the W-2 Forms
* Please bring in a copy of all the following pages to leave here
- A Copy of the current checking and/or savings bank account’s statement. (Bank printouts are acceptable)
- Any award letters for any pensions or annuities of anyone in the household
- Your Social Security Card
- Insurance card (If you have health insurance or medication insurance)
- Any AFDC checks you receive, including award letter for food stamps
- If you have ever been on Medicaid or been denied Medicaid, we will need the denial letter ending the services
- If you have zero income, call your patient advocate here at the clinic and we will tell you what we need
- Please return the application within 30 days
IF YOU ARE CURRENTLY ON MEDICAID, YOU ARE NOT ELIGIBLE FOR OUR SERVICES
Download an application for help here.