Specialty Care Clinic's Eligibility Form

Eligibility documents must be submitted by your appointment date.

PROOF OF GEORGIA RESIDENCY

Provide ONE of the following:

• Current utility bill (within 30 days) with your name and address (phone, power, water, or gas)
• Current mortgage or rent statement from the past 30 days
• Any medical bill from the past 30 days (doctor or hospital)
  Voter ID with your name and address
• Vehicle registration with your name and address
• Current SSDI, SSI, TANF letter with your name and physical address
• Current paystub showing your name and physical address
• Statement of Support (if no proof of residence/address is in your name)

 PROOF OF INCOME

 Provide ONE of the following:

• Paystubs (for the most recent 30 days of consecutive income)
• Tax returns/W-2
• SSI, SSDI, Pension, or Veterans Award Letter
• Child Support and/or Alimony
• Bank Statement (can only be used to prove SSI, SSDI, Pension, or Annuity)
• Statement of Support (if paid in cash or explanation of no income)

 

NOTE: You must provide documentation of income for all household members. Household is defined as you, your married spouse, dependent children, and adult dependents.