Do you qualify for our 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.
| Size of Household | 1 | 2 | 3 | 4 | 5 | 6 | 7 |
| 150% of Poverty | $19,140 | $25,860 | $32,580 | $39,300 | $46,020 | $52,740 | $59,460 |
- 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.
If you qualify, you will need to set up a financial screening appointment. Call us at 478-953-7770 to set up your appointment.
What to bring to your financial screening appointment
Income Verification if you or your family members are working:
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 consecutive Paycheck Stubs | Last 3 consecutive Paycheck Stubs | |
| Last 3 consecutive months of Bank Statements | Last 3 consecutive months of Bank Statements | |
| W-2/1099 VERIFICATION | W-2/1099 VERIFICATION | |
| Picture ID | Picture ID | |
| Utility Bill | Utility Bill |
Income Verification if you or your family members are not working:
| Patient Information (or Patient’s Father) |
Spouse’s Information (or Patient’s Mother) |
|
| Proof of Government Assistance | Proof of Government Assistance | |
| WG-15 from Labor Dept. | WG-15 from Labor Dept. | |
| UNEMPLOYMENT LETTER | UNEMPLOYMENT LETTER | |
| Picture ID | Picture ID | |
| Utility Bill | Utility Bill | |
| OTHER WAGES (child support, alimony, food stamps, pensions, rental assistance, retirement income, award letters) | OTHER WAGES (child support, alimony, food stamps, pensions, rental assistance, retirement income, award letters) | |
| DD214 for veterans | DD214 for veterans |
***income from all wage earners, as well as government income will be calculated. Household income and Family Size will help determine eligibility.
Patient Forms |