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To be a patient at the Free Clinic a person cannot have any health insurance.  He/she cannot have medical assistance from the Pennsylvania Department of Welfare or be eligible for Medicare.  The person must have a photo ID and show proof of total household income.  The person will be required to obtain a denial letter from the Medical Assistance Office within 90 days.  The person will have an Intake appointment to determine if he/she is eligible for clinic services before seeing the doctor.  All forms needed are at the end of this page.

PHOTO ID: a photo ID may be a current or past driver’s license.  It may be from any state.  Other acceptable ID’s are state issued ID cards, student ID cards, passports, or work ID cards.

PROOF OF INCOME:   Proof of total household income is required before a person is seen by the doctor. Total household income means all the income for every person living in the same household.  Proof of income may be pay stubs, letters from Social Security, Department of Welfare, Pension, or disability offices stating what the patient receives.  The preceding year’s income tax return or proof of non-filing (4506T) will also be required (This form available at the bottom of the page.)

MEDICAL ASSISTANCE DENIAL LETTER:   All patients will be required to obtain a denial letter from the Welfare Office within 90 days to remain eligible for clinic services.  The only exception to this is patients who are getting pre-employment or school physicals. To learn more about Medical Assistance, follow the link below to the COMPASS website.

LINK TO Medical Assistance website

Proof of income and medical assistance denial letters must be renewed annually.   1040’s or other proof of income must be supplied by March 15, and medical assistance denial letter based on the date of the original letter.

Patient Health Information UPDATED 20141Download 
Patient Demographic Sheet UPDATED20144Download 
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