ELIGIBILITY APPLICATION

For eligibility interviews, please print, complete and bring the eligibility application to your eligibility interview.

WAGE VERIFICATION LETTER

A completed wage verification letter can be used in place of presenting a months worth of recent paycheck stubs.

Medical Records Release

For a copy of your medical records, please print, complete and bring or mail the medical records release form to the Clinic.

 

Notice of Privacy Practices / Aviso Respecto a Polizas de Próvacidad