New Patient/Renewal Application Form
To qualify, you must be an uninsured adult living in Madison County, Virginia, with household income equal to or less than 300% of the Federal Poverty level. If your household income is equal to or less than 138% of FPL, you must also apply for Medicaid through the State of Virginia. For those who qualify, Medicaid provides more comprehensive coverage than the Free Clinic can offer. Our volunteers are trained to assist you with your Medicaid application if needed. Please check your eligibility at https://coverva.org/
NOTE: if you have no income and are not required to file taxes, please have the person who covers your expenses (i.e., food, rent) complete this letter of support.