What to bring

As a Federally Qualified Community Health Center we are required by law to obtain all of this information for our records.

You will not be eligible for the sliding fee scale discount until you bring all required information.

Once all required information is received, you may be entitled to a refund if you qualify for the sliding fee scale.

  • Patients with Insurance, Medicare or Medicaid

    Bring the following documents at each visit:

    • Photo ID
    • Insurance Card
  • Patients without any type of insurance (Sliding Fee Eligible)

    Bring the following documents for your first visit and once a year thereafter:

    1: Proof of Identification:

    • Current Photo ID (if no photo id, see front desk clerk for Affidavit)

    2: Proof of Income: (Only one of the following is required)

    • Minimum of two current paycheck stubs and proof of income for all in your household (or notarized letter from your employer) or
    • Income Tax Return or W2 Form (most recent) or
    • Disability/Worker’s Compensation Notification Form or Social Security Notification Form or Pension/ Retirement Statement or Veteran’s Benefits Statement or Child Support Court Award (must include amount of benefits) or
    • Current Food Stamp Summary or
    • Other documents showing proof of income (such as letter of reference from one the following: Employer, Minister/Priest, etc. on a company or official letterhead)

    3: Proof of Number of Dependents: (Only one of the following is required)

    • Previous year’s Income Tax Return (most recent) or
    • Any decision letters indicating that the patient has legal responsibility for the child, such as, court order guardianship papers or custody papers or
    • Birth Certificate for each child age 18 and younger
  • Self Employed Persons

    Bring the following documents at first visit and once a year thereafter:

    • Current Photo ID (if no photo id, see front desk clerk for Affidavit)
    • Most recent federal tax return to verify income and unemployment insurance wage determination from the Georgia Dept. of Labor.
  • Unemployed Persons

    Bring the following documents at first visit and once a year thereafter:

    • Current Photo ID (if no photo id, see front desk clerk for Affidavit)
    • Unemployment insurance wage determination from the Georgia Dept. of Labor and the most recent federal tax return to verify income and/or a current 30day separation notice.
  • Homeless

    Bring the following documents at first visit and once a year thereafter:

    • Current Photo ID (if no photo id, see front desk clerk for Affidavit)
    • Patient will be asked to sign a Certification for Homeless Form to certify present situation. (see front desk clerk for form)
  • Undocumented Immigrants

    Bring the following documents at first visit and once a year thereafter: Information is NOT shared with Immigration Services.

    • Current Photo ID (if no photo id, see front desk clerk for Affidavit)
    • Patient will be asked to sign a Certification for Undocumented Immigrants Form to certify present situation. (see front desk clerk for form)