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Do I Qualify?

PamandpatientEffective January 1, 2019, In order to be eligible for care at Western Tidewater Free Clinic, an individual must meet the following criteria.

Clients must have the following items for the Clinic to be able to determine their eligibility status. Clients must schedule appointments to complete the eligibility paperwork. Upon completion of the eligibility appointment, patients may be scheduled for a medical appointment. The eligibility process must be done every 12 months so that we are certain that we focus our services on residents that continue to meet our eligibility criteria.

Eligibility Checklist 

  • Picture ID
  • Proof of Social Security Number or valid Tax Identification Number (TIN)
  • Proof of Residency (current bill or other 1st class mail dated within the past 2 months; personal mail is NOT accepted)
  • Proof of Income for those contributing to the household expenses (including anyone listed as a dependent on your tax return or anyone who has claimed you on a tax return)
  • IRS Form 1040 (if you filed taxes for the prior year)
  • W-2/1099 form from last year if self-employed
  • One month of current consecutive pay stubs (if currently employed) - stubs must show pay period dates and gross amount earned for that period
  • Disability Letter (if on disability)
  • Proof of alimony/child support (if you are receiving these benefits)
  • Food Stamp Award Letter with household size noted and award period defined (if you are eligible for food stamps)
  • Completed Food and Shelter Form or Letter of Support (if unemployed and someone is providing you with a place to live or financial support)
  • Affidavit of Income if unemployed (form is provided by the Clinic)
  • Affidavit of residency if homeless (form is provided by the Clinic)
  • Letter from a homeless shelter (if you are residing in a shelter)