Become a Patient

Patient Eligibility for Semi-urgent Medical Services

• Must be a resident of Charlotte County, Florida
• At least 18 years of age
• Have no Medicaid, Medicare or private health insurance
• Annual household income must be at or below 200% of the Federal Poverty Level for the size of your family.
  • For a family size of one (a single person), that means you can earn up to $29,160 per year (approx. $2,430 per month)
  • For a family of four, the limit is $60,000 per year (approx. $5,000  per month)
  • These figures are based on US DHHS Federal Poverty Guidelines (Federal Register; 1/24/23), and are subject to change without notice. Get the information here.
  • Some exceptions may apply; please call 941-766-9570 for more information.

You will need the following documents at your first screening appointment in order to receive services:

Download and print this Patient Packet. (2.5 Mb file size) If you have any questions as you are filling out your packet and gathering the supporting documentation, please don’t hesitate to call the Clinic at 941-766-9570.

1. Photo identification

2. Proof of current Charlotte County address – 1 document of proof

• Examples of documentation – photo ID, utility bill, lease/rental agreement, current pay stub with address, vehicle registration
• If homeless, we need a letter from The Homeless Coalition, Jesus Loves You Ministry, or other benefit agency. And, if not registered through “coordinated entry”, we will still see you but you will need to provide a letter of certification of homelessness from one of these agencies within 30 days.

3. Provide Proof of income or Explanation of How You Live With No Income – Needed for all family members (i.e. patient/spouse/significant other/child)

• NOTE: Must provide #1 and #2
  1) Current Social Security Earnings Statement
  2) Previous year Income Tax Return or proof you did not file
  
• NOTE: Must provide for all in your family unit
  3) 1 month of current pay stubs needed for each member of the family
  4) Current Bank Statements (all checking & savings) needed for each member of the family
  5) Current Unemployment letter stating amount to be received needed for each member of the family
  6) Current Social Security Benefits (retirement, disability, dependents, and survivors) award letter stating amount to be received needed for each member of the family
•  NOTE: Must provide if #3, #4, #5, and/or #6 all equal $0 (zero dollars)
  7) Explanation of How You Live With No Income

4. Copy of medical records (if needed)

Once packet is complete, and all supporting documentation has been gathered, please call the Clinic at  (941) 766-9570 to make a screening appointment.