How to Become a Patient 

How to Receive Care: Medical care is provided free of charge for patients between the ages of 19 and 64 without health insurance and with income up to 200% of the Federal Poverty Level. Clients must first go through the financial screening process to verify eligibility.

Requirements:

• Must be a resident of Montgomery, Autauga, Elmore, or Lowndes Counties

• Must be between the ages of 19 and 64

• Must have a Social Security number and proof of that number

• Must NOT have Medicare, Medicaid, VA medical benefits, or private insurance

FINANCIAL SCREENING PROCESS: Screening is done by mail, email, or in person. To screen as a new patient or to re-screen, please print the application and email or mail the application and additional documents. If you would like additional assistance, you may also visit the clinic to complete your application in person.

Email: henry.llorens@med-outreach.org

Mail: Medical Outreach Ministries, ATTN: Screening, 5741 Carmichael Parkway, Montgomery, AL 36117

Forms:

Click HERE to print the application and fill out before your screening if you are able.

Click HERE to print the notarized letter form. 

Items needed for financial screening (not all will apply to you):

• Completed application - pages 2-14

• Identification - Must be current, picture ID. Submit a copy of one of the following: Driver’s License, State issued ID, Voter ID, Salvation Army ID

• Social Security Card - Copy of your card is preferred. If you do not have a social security card, an official Federal or State tax document with your social security number on it is acceptable.

• Tax Information

  • If you do NOT file taxes:

    • Form 4506-T must be signed and submitted. Form found on page 16 of packet.

  • If you file taxes:

    • Submit Form 1040, pages 1-2 of most recent return. Prior to April 15, a previous year’s return is acceptable. After April 15, the current year’s return is required.

• Income Information

  • If you have NO income, provide ONE of the following:

    • Notarized letter signed by someone who financially assists you – Form found on page 15 of packet.

    • Food Stamp Letter

  • If you have income, include any that apply to you:

    • Paycheck stubs - 3 most recent paycheck stubs

    • Benefits letter (ex. SSI, unemployment, food stamps, housing voucher, other government benefits) – Must be current and list your name and monthly amount.

    • Proof of child support/alimony payments that you receive

    • Most recent bank statement - Must list your name and beginning and ending balance.

    • Home Appraisal value (printout from county is acceptable)

      • Montgomery: http://revco.mc-ala.org/

      • Autauga: https://autauga.capturecama.com

      • Elmore: http://www.elmorerevenuecommissioner.net

      • Lowndes: https://www.alabamagis.com/lowndes/

Once complete, submit your application by mail, email, or hand delivery. Please do not fax.

AFTER SCREENING: Once approved, you will receive a Charity Care letter from Baptist Health. This letter is important and must be kept in a safe place and provided at every encounter at Baptist Labs, Radiology, Emergency Room or specialist offices. If you lose the letter, you will need to contact the Baptist Health Business Office at (334) 747-4270 to obtain a new one. Medical Outreach Ministries is NOT responsible for your Baptist Charity Care letter.

RE-SCREENING: All patients must re-screen annually to verify continued eligibility. You MUST be approved before the day of your next appointment or next specialist appointment in order to continue to be eligible for services at Medical Outreach Ministries.