Welcome to our application process
We look forward to serving you
Once you submit your application through the form below, our Intake Coordinator will contact you within 2 business days. Call (704) 841-8882 and select option 1 if you have any questions about the application process.
Patient Requirements
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- Live anywhere in Mecklenburg, Union or Gaston County, NC
- Be 14-64 years old
- Not have Medicaid (Family Planning Medicaid does not disqualify), Medicare, VA, Marketplace insurance, or private insurance
- Be at or below 250% of the current year’s Federal Poverty Guidelines (click HERE to be redirected to the federal poverty level chart).
What You Will Need to Apply
At least one document must be submitted from each of the three categories below (three documents total):
A government, work, school, or organization-issued photo ID is required for the proof of identity; it cannot be expired. Please DO NOT upload birth certificates.
The proof of residency must include applicant’s name and current address, and be dated within the last 30 days.
- Utility Bill
- Hospital Bill
- Advertisement
- Postmarked Envelope
Please provide documentation for each income source for applicant and/or spouse/significant other living in the same household. Please provide as many as apply.
- Last 30 days of paystubs.
- If paid in cash, a letter dated and signed by employer stating how many hours worked per week and rate of pay per hour.
- If self-employed, copies of 3 most recent, consecutive bank statements (include all pages, even if blank).
- Copy of award letter showing monthly benefit for any additional income such as Unemployment, Disability, Social Security, etc.
- If neither the applicant nor spouse/significant other has income, please provide a completed letter of support stating how the applicant is supported financially. The letter must be signed and dated by the person providing support, must state the type of support they are providing, their address and contact number, and their relationship to the applicant. Click HERE to see an example of a letter of support.
- Copy of previous year’s Tax Return.
If there is a document that you would like to provide as part of the application that is not listed above, please give us a call to confirm the document can be accepted.