1. May include, but is not limited to, consecutive bi-weekly pay stubs for 30-days (two bi-weekly pay stubs), consecutive weekly pay stubs for 30-days (four weekly pay stubs), federal income tax return from previous year, unemployment office documentation, or acceptable letter from pastor/minister.

2. Recent documentation is required for proper processing and approval of application. ‘Recent’ is defined as within 60-days of application.

3. If the proof of income presented does not belong to the patient, the person or persons in the household must appear with picture identification during the application process.

4. If documentation is not available or incomplete for medical services, procedures and supplies, the patient will need to pay the full office visit fee and will be allowed to sign a one-time 30-day waiver. There is no 30-day waiver for the pharmacy prescription medications or for dental services.