Free Clinic Patient Application

New Patient Application Checklist

Please make sure all items are included with the application. We do not accept the application without all the information needed. Required fields are marked with an asterisk. Thank you!
Included Documents:

Completed ApplicationColor Copy of Photo IDSocial Security Number (We do not require a copy)Proof of Household Income This should be at least ONE of the following: Copy of at least 2 RECENT pay stubs, W-2 form, or tax form from previous year, Child Support Printout, No income Questionnaire.
Upload Valid Photo ID (FRONT)

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Upload Valid Photo ID (BACK)

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Upload Proof of Income Documents

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Free Clinic of Meridian Authorization to Verify Patient Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security Number*
I hereby authorize the Free Clinic of Meridian to verify my income and availability of insurance by contacting my employer, my spouse's employer, the Mississippi Office of Medicaid, and/or the Office of Medicare.

I understand that having a household income above 200% of the Federal Poverty level for a household of my size or having any type of insurance will disqualify me from receiving care at The Free Clinic of Meridian.
Signature*

Clear
Date*

MonthDayYear
Date

QUESTIONNAIRE FOR PATIENTS WITH NO INCOME

If you presently DO NOT have any income coming into your household, please answer the following:
1. Has anyone in your HOUSEHOLD received income this month such as cash, checks, gifts?

YesNo
If so, how much?
2. Have you received financial assistance through any of the following community agencies in the past three months?

Multi-CountyWesley HouseSalvation ArmyDHS/SSI
If yes, please describe the assistance you receive below:
Do you receive child support?

YesNo
If so, how much?
How are you paying for your monthly bills? This includes rent, light bill, phone, gas, food, etc.
Should be Empty:

New Patient Application Checklist