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, GAP or Veteran’s Benefits
Have lived in the US for at least 1 continuous 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: Current Utility Bill or Lease Agreement
Proof of residing in the US for at least 1 continuous year such as one of the above or one of the following:
Passport, pay stubs, 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
 Current Award Letter for Social Security, Disability, TANF, Food Stamps
Current Medicaid, Medicare, Disability 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 1 month• statement of 1 month gross earnings from employer (on notarized letterhead) Must be most current month
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. Supporter must provide their current proof of income, current proof of address and a copy of signed tax return (1040) Support Letters and Notary available at clinic
Benefits/Assistance • Award letters from any of the following:Social Security, Disability, Retirement/Pension, Food Stamps, TANF, Housing Assistance (HUD) Must be most current statement
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.