Who Qualifies for Services?
- You must live in Houston, Peach, Taylor or Crawford County
- You must be uninsured which means that you are not:
- covered by your spouse’s insurance
- approved by Medicaid, Peachcare or the VA
- Your family’s gross income must be 150% of poverty level or less.
- You must provide proof of your family income.
- Current W-2 for, IRS 1040 Form (income tax return), wage stubs, other letters or documents issued by the payer of the income or 1099 Forms.
- You must provide identification which shows your birthday & your picture
- You must provide a utility bill with your name and address as proof of living in the above stated counties.
Forms
Items to bring to a Financial Screening Appointment
Income Verification
The following items must be presented at the time of a Financial Screening, in order for an application to be processed:
Patient Information
(or Patient’s Father) |
|
Spouse's Information
(or Patient’s Mother) |
| Last 3 Paycheck Stubs |
|
Last 3 Paycheck Stubs |
| Last 3 months of Bank Statements |
|
Last 3 months of Bank Statements |
| W-2 VERIFICATION |
|
W-2 VERIFICATION |
| Copy of Tax Return |
|
Copy of Tax Return |
| Proof of Social Security or Disability Benefits |
|
Proof of Social Security or Disability Benefits |
| Proof of Government Assistance |
|
Proof of Government Assistance |
| UNEMPLOYMENT LETTER |
|
UNEMPLOYMENT LETTER |
| Picture ID |
|
Picture ID |
| Utility Bill |
|
Utility Bill |
| OTHER WAGES (child support, alimony) |
|
OTHER WAGES (child support, alimony) |
| |
|
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Income from all wage earners, as well as government income will be calculated. Household income and Family Size will help determine eligibility.
|
The number to support Care For Life Clinic