Apply for services


Patient Intake
Moss Free Clinic Logo

Please provide the information below to start your application. Please note that we do not provide maternity care. After you click “Submit,” look to the bottom of the page for a message indicating that your application went through.

Address *
Address
City
State/Province
Zip/Postal
May we text you at this number?
Communication Preference *
Include Spouse, Social Security, Unemployment, Child Support and all other income.
This is the same number claimed on taxes.
Do you have health insurance? *
Do you have Medicaid? *
Do you have Medicare? *
Do you have medical coverage through the Veteran’s Administration? *
Have you ever been a patient of the Lloyd F. Moss Free Clinic? *
Do you have an urgent need to see a healthcare provider?
Monday
Tuesday
Wednesday
Thursday
Friday
Picture ID
Upload Picture ID
Maximum upload size: 2MB
Proof of Residency
Picture ID plus utility bill, bank statement, car or voter registration, residential lease
Upload Proof of Residency
Maximum upload size: 2MB
Income Documents 1
Most recent tax return, including Schedule C if applicable, most recent W2 for all employers
Upload Income Documents 1
Maximum upload size: 2MB
Income Documents 2
Award letter from Social Security, disability, pension, food stamps, housing assistance, unemployment benefits
Upload Income Documents 2
Maximum upload size: 2MB
Income Documents 3
Financial Support Letter
Upload Income Documents 3
Maximum upload size: 2MB
Income Documents 4
Two most recent pay stubs for each employed person
Upload Income Documents 4
Maximum upload size: 2MB
Income Documents 5
Wage and income statement and/or verification of non-filer from IRS
Upload Income Documents 5
Maximum upload size: 2MB
Income Documents 6
Copy of child support and/or alimony orders
Upload Income Documents 6
Maximum upload size: 2MB
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