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Lloyd F. Moss Free Clinic
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Apply for services
Apply for services
Please provide the information below to start your application.
Name*
Address 1*
Address 2
City*
State*
Zip*
Phone #*
May we text you at this number?
Yes
No
Email*
Communication Preference*
[radio* communication-pref id:communication-pref-phone use_label_element "Phone"]
[radio* communication-pref id:communication-pref-email use_label_element "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 Health Care 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 indicate if you have the document or not.
Picture ID
Yes
No
Proof of Residency
Picture ID plus utility bill, bank statement, car or voter registration, residential lease
Yes
No
N/A
Income Documents 1
Most recent tax return, including Schedule C if applicable, most recent W2 for all employers
Yes
No
N/A
Income Documents 2
Award letter from Social Security, disability, pension, food stamps, housing assistance, unemployment benefits
Yes
No
N/A
Income Documents 3
Financial Support Letter
Yes
No
N/A
Income Documents 4
Two most recent pay stubs for each employed person
Yes
No
N/A
Income Documents 5
Wage and income statement and/or verification of non-filer from IRS
Yes
No
N/A
Income Documents 6
Copy of child support and/or alimony orders
Yes
No
N/A
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