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Lloyd F. Moss Free Clinic
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Apply for services
Patient Intake
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
Address
Address
City
City
State/Province
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
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
Drop a file here or click to upload
Choose File
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
Drop a file here or click to upload
Choose File
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
Drop a file here or click to upload
Choose File
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
Drop a file here or click to upload
Choose File
Maximum upload size: 2MB
Income Documents 3
Financial Support Letter
Yes
No
N/A
Upload Income Documents 3
Drop a file here or click to upload
Choose File
Maximum upload size: 2MB
Income Documents 4
Two most recent pay stubs for each employed person
Yes
No
N/A
Upload Income Documents 4
Drop a file here or click to upload
Choose File
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
Drop a file here or click to upload
Choose File
Maximum upload size: 2MB
Income Documents 6
Copy of child support and/or alimony orders
Yes
No
N/A
Upload Income Documents 6
Drop a file here or click to upload
Choose File
Maximum upload size: 2MB
Submit
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