forms
Eligibility Application
For eligibility interviews, please print, complete and bring the eligibility application to your eligibility interview.
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Wage Verification Letter
A completed wage verification letter can be used in place of presenting a month's worth of recent paycheck stubs.
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Statement of Support
A completed statement of support can be used in place of presenting a month's worth of recent paycheck stubs, if you are being financially supported by someone besides yourself or your spouse.
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Medical Records Release
For a copy of your medical records, please print, complete and bring or mail the medical records release form to the Clinic.
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Notice of Privacy Practice and Rights & Responsibilities
Please review these documents to know the company’s privacy practice and rights & responsibilities