Patient Eligibility

ELIGIBILITY TIMES

 • Tuesdays: 1-4 pm • Wednesday: 9- 12 noon • Thursday: 4 – 7 pm

ELIGIBILITY REQUIREMENTS

No medical insurance
At or below 200% of poverty level
Not eligible for FAMIS, Medicare or Medicaid
Have lived in the US for at least 1 year
Patients must live in our service area which includes: Newport News, York County, Williamsburg, Poquoson, and James City County

WHAT TO BRING

Bring any that apply

Photo ID, driver’s license, passport
Social Security Card (ITIN if undocumented, no documentation is required)
Proof of residence: Utility Bill, Car or Voter Registration or Lease Agreement (bring one)
Proof of residing in the US for at least 1 year such as one of the above or one of the following:
pay stub, receipts, bill, school enrollment, birth certificate of child born in US
Copy of most recent signed tax return transcript (1040)
If taxes were not filed a 4506-T will be required to be signed at the clinic
W2’s for all employers (if taxes were not filed)
Current Medicaid Denial Letter (if applied or denied)
Most recent Proof of Income for each family member that contributes to household income.
(Accepted documents shown below)

ACCEPTED PROOF OF INCOME DOCUMENTS

Bring any that apply

INCOME SOURCE DOCUMENTATION NOTES
Regular Employment • Pay stubs for 2 months• statement of 2 month’s gross earnings from employer (on letterhead)
Self-Employment • Schedule C included with Tax Transcript (1040)• Notarized copy of Daily Earnings Statement Worksheet Daily Earnings Statement Worksheet and Notary available at clinic
Unemployment • Unemployment Benefits award letter from Unemployment Commission
Zero Income • Notarized Support Letter from supporter stating financial circumstances of patient Support Letters and Notary available at clinic
Benefits/Assistance • Award letters from any of the following:Social Security, Disability, Retirement/Pension, Food Stamps, Housing Assistance Must be most current statement (within the last 30 days)
Child Support/Alimony • Copy of court order (if available)

It is the patients responsibility to have their Lackey Clinic Card renewed by the expiration date.