Qualifying

 

Find Out if You Are Eligible

Qualification is effective for one year. Re-qualification is just like the initial qualification, requiring a new application and all the documents. Applications are available outside our door at any time or you may download an application (it will need to be printed and filled out). You can also request an application be mailed to you.  Once you have completed your application, you must appear in person with all of your documentation between 3 p.m. and 6 p.m. on Mondays and Wednesdays. No appointment needed, you will be seen on a first come first served basis. The interview can take anywhere from 30 minutes to an hour.

The following are some of the qualifications that need to be met in order to become a patient at the clinic: 
1. You have lived in West Volusia County for 1 month or more
2. You have no applicable health insurance
3. Your household income does not exceed 300% of the Federal Poverty Level (FPL).

 

Application

  1. The application must be fully completed and all pertinent paperwork must be included.
  2. Bring the completed application and paperwork to the clinic on a Monday and Wednesday from 3-7PM. No appointment needed, you will be seen on a first come first served basis.
  3. Applications and documents must be submitted IN PERSON. We DO NOT accept applications by mail, email, or fax. You MUST meet with the Qualifier.

Bilingual applications are also available upon request.

 

Patient Application Form
Good Samaritan Clinic (GSC) is a faith-based primary care clinic.

Documents Required for Qualification

  1. Completed application
  2. Proof of Identification – Valid Government Issued Photo ID (ex: Driver’s License)
  3. Proof of Residency showing: current address, applicant name/spouse name (Bring one of the following)
    • Current rent or lease contract for rented home -or-
    • Most recent property tax bill for owned home -or-
    • A current month utility bill or service bill -or-
    • HOMELESS ONLY: a current registration letter from The Neighborhood Center 434 S. Woodland Blvd. DeLand, FL 32720
  4. Proof of Income and Assets (bring all that apply)
    • If you or anyone in your household is employed, you must show proof of wages received.
    • If you or anyone in your household has a bank account, you must show all pages of most recent month banking statement digitally or printed out.
    • If you or anyone in your household receives SNAP (food assistance), you must show your Benefit Letter or EBT card
    • If you or anyone in your household is retired or on disability, you must show your most recent letter from Social Security
    • If you or anyone in your household earns any other income, you must show proof with dollar amounts.
    • If you have no income and someone supports you, you must complete the Verification of Support form found in the application. 

* Proof of documentation can be digital. For example, showing your digital bank statement.

** Household consists of a family unit or a single adult. Family unit means one or more persons living in the same house who are related by blood, marriage, law or who are cohabitating partners.  If the dwelling includes more than one family or more than one unrelated individual. eligibility determination is separate for each family unit or unrelated individual, and not for the dwelling as a whole. A single adult, 18 and over, living with relatives is considered a separate family for income determinations purposes. However, a student, age 18-21, living at home, shall be considered a family member.