MEDICAL OUTREACH MINISTRIES
ELIGIBILITY SHEET FOR BECOMING A PATIENT

You will need to go through a financial screening process to see if you are eligible for services at the Medical Outreach Ministries Family Health Center. We start screening patients on Monday and Wednesday mornings at 9:00 A.M. The screening sign up sheet is put out for signing at 7:45 a.m. Monday and Wednesday mornings. All screenings are done on a first-come first-served basis and are limited to the first 10 people to sign up. Be aware that there may be days when we do not have enough volunteer screeners to handle 10 people, so some people will be asked to come back on another screening day.

INITIAL REQUIREMENTS

1. Must be a resident of either Montgomery, Elmore, or Autauga County.
2. Must be age 19 - 64.
3. Must have a Social Security number and proof of number.
4. Must NOT have or be eligible for Medicare, Medicaid, or VA medical benefits or private insurance. If you have been denied any of these, you must bring in the denial letter (no matter how long ago you were denied).
5. Household income less than 200% of Federal Poverty Level.

All applicants must bring the following:

• Proof of current address (Any recently delivered mail addressed to you at your current street address). P. O. Boxes will not be accepted. Address information cannot be older than 60 days.
• Picture ID.
• Proof of Social Security number-Social Security Card.
• Last Income Tax Return (Form 1040) with W-2’s and 1099 forms if you or your spouse filed a tax return.

- AND -

Any of the following that apply to you and anyone else living in your household regardless of whether you are related or not:

• Proof of all household income.
• Three current pay stubs for all individuals living in the household.
• Current pension stubs or insurance income.
• Proof of current Social Security payments.
• Proof of current disability/SSI payments.
• Proof of current unemployment compensation.
• Proof of current alimony payment.
• Proof of current child support payment.
• Proof of current (TANF) or (AFDC) payment.
• Verification of utility or housing allowance, including lease.
• Verification of food stamp benefits (Notice of Action is only acceptable documentation).
• Verification of amount received from rental property or renter in household.
• Verification of other assistance (family, friends, First Baptist Church, Frazer United Methodist, Salvation Army, etc.) This should be a statement dated and signed by the person or agency giving assistance stating the dollar amount and frequency of assistance.