Directions for Application:
Please bring in your own copies of all requested information. We are unable to provide this service for you.

If you are currently on Medicaid, you are not eligible for our services.

When your application is completed call: 726-4562 to set up an appointment with your patient advocate. Your patient advocate will have you come in to review your application.

All patients applying for the clinic services must have a diagnosis of at least one of the following four diseases:

• Diabetes
• Hypertension
• Chronic Lung Disease
• Chronic Heart Disease

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• 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 ORIGINAL statement. (Bank printouts are not acceptable)
• Any award letters for any pensions or anniuties 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