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 month's worth of recent paycheck stubs.

 

Statement of Support

A completed statement of support can be used in place of presenting a month's worth of recent paycheck stubs, if you are being financially supported by someone besides yourself or your spouse.

 

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