Apply for Help

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Qualifications


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.

linerDirections for Application

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.