Lloyd Moss Free Clinic

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.

Name *

Address *

Address

City

State/Province

Zip/Postal

Phone # *

May we text you at this number?

Yes

No

Email *

Communication Preference *

Phone

Email

Date of Birth *

Monthly Income *

Include Spouse, Social Security, Unemployment, Child Support and all other income.

Number of People in Household *

This is the same number claimed on taxes.

Do you have health insurance? *

Yes

No

Do you have Medicaid? *

Yes

No

Do you have Medicare? *

Yes

No

Do you have medical coverage through the Veteran’s Administration? *

Yes

No

Have you ever been a patient of the Lloyd F. Moss Free Clinic? *

Yes

No

Who was your last healthcare provider?

How long has it been since you have seen a healthcare provider?

Do you have an urgent need to see a healthcare provider?

Yes

No

When can you come in for an interview?Bring all your documents with you.

Monday

Morning

Mid-Day

Afternoon

Evening

Tuesday

Morning

Mid-Day

Afternoon

Evening

Wednesday

Morning

Mid-Day

Afternoon

Evening

Thursday

Morning

Mid-Day

Afternoon

Evening

Friday

Morning

Mid-Day

Afternoon

Evening

Here’s a list of documents you’ll need to apply for services:Please attach all you can, using a scan, or taking a picture with your phone.Please be sure we can read the document – that the entire page is clear and legible. You can upload as many pages for each as you need.Please indicate yes if you have uploaded it.

Picture ID

Yes

No

Upload Picture ID

Maximum upload size: 2MB

Proof of Residency

Picture ID plus utility bill, bank statement, car or voter registration, residential lease

Yes

No

N/A

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

Yes

No

N/A

Upload Income Documents 1

Maximum upload size: 2MB

Income Documents 2

Award letter from Social Security, disability, pension, food stamps, housing assistance, unemployment benefits

Yes

No

N/A

Upload Income Documents 2

Maximum upload size: 2MB

Income Documents 3

Financial Support Letter

Yes

No

N/A

Upload Income Documents 3

Maximum upload size: 2MB

Income Documents 4

Two most recent pay stubs for each employed person

Yes

No

N/A

Upload Income Documents 4

Maximum upload size: 2MB

Income Documents 5

Wage and income statement and/or verification of non-filer from IRS

Yes

No

N/A

Upload Income Documents 5

Maximum upload size: 2MB

Income Documents 6

Copy of child support and/or alimony orders

Yes

No

N/A

Upload Income Documents 6

Maximum upload size: 2MB

Apply for services