May we text you at this number?
Do you have health insurance?
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?
Proof of Residency
Picture ID plus utility bill, bank statement, car or voter registration, residential lease
Upload Proof of Residency
Income Documents 1
Most recent tax return, including Schedule C if applicable, most recent W2 for all employers
Upload Income Documents 1
Income Documents 2
Award letter from Social Security, disability, pension, food stamps, housing assistance, unemployment benefits
Upload Income Documents 2
Income Documents 3
Financial Support Letter
Upload Income Documents 3
Income Documents 4
Two most recent pay stubs for each employed person
Upload Income Documents 4
Income Documents 5
Wage and income statement and/or verification of non-filer from IRS
Upload Income Documents 5
Income Documents 6
Copy of child support and/or alimony orders
Upload Income Documents 6