Apply for help

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.

Directions 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

Although the Affordable Care Act (ACA) has enabled some low income individuals to obtain health insurance, it is also true that the need for the charity care given by The Broad Street Clinic will continue. Many of our patients fall into a “coverage gap”– unable to afford insurance and not qualifying for a subsidy. Further, they may qualify for one of the many exemptions and not have to pay the fine for being uninsured.

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