To download an Eligibility form, click on the links below, or visit the Forms tab for more information. Eligibility forms are also available in the Eligibility office.

Eligibility Application

Aplicación de Eligibilidad

To receive services at San José Clinic, low-income, uninsured individuals and families must first complete an eligibility interview.  Medicaid, Medicare, Affordable Care Act plans are also considered different types of health insurance coverage.  Those that qualify for services will receive a patient account, providing them access to services.

Eligibility interviews are conducted on a walk-in basis from 8 a.m. to 4 p.m. Monday through Friday. No appointment is necessary.

Please bring:

1. Photo Identification
Please bring one of the following for each adult:

  • State Driver’s License or Identification Card (current or expired)
  • Passport or Visa
  • U.S. Immigration documents
  • Student or work ID*
  • Photo ID from another country
  • Other forms of photo identification*

*If a non-government issued ID is provided, another form of ID will need to be provided (such as birth certificate, marriage license, social security card, etc.) 

Please bring all of the following for each child:

  • Birth Certificate or Birth Fact Record
  • Medicaid or CHIP ID cards

2. Proof of Household Income

Please bring all documents that you have.

  • One month’s worth of recent pay stubs
    • If you do not receive paystubs, a completed wage verification letter from employer will be accepted.
  • Most recent tax return
  • Letter of support
  • Welfare benefit documents (TANF and Food Stamps)
  • SSI or Social Security certification documents
  • Unemployment documents / Worker’s compensation
  • Child support documents

3. Proof of Address

  • Any piece of mail that is delivered through the Postal Service with the patient's name and address.

Please feel free to call 713-490-2610 if you have any questions.