• If you have Medicaid, please bring your gold Medicaid card with you
• If you have Medicare coverage, please bring your red, white, and blue Medicare card
• If you have private insurance, please bring your insurance identification card with you

Fees will be charged on a sliding fee scale based on your family’s income for the current month. Your family may include any person who lives with you and is related to you by blood, marriage, law, or conception. You may be asked to provide verification of your family’s income. Depending on your family income, you may be asked to provide proof that you have applied for Medicaid.

Wages or Salaries

• Paycheck stubs or wage slips or a signed and dated statement from the employer

Income from Self-Employment

• Previous year’s income tax statement, or
• Most recent quarterly income tax statement, or
• Personal business records

Child Support or Alimony

• Check stubs, or
• A computer printout issued by the court of domestic relations, or
• A court order for child support or alimony (if the payer is complying), or
• A signed and dated statement from the payer

Unemployment Compensation, or
Worker’s Compensation, or
Social Security, or
Veteran’s Pension, or
Other Pensions or Annuities, or
Dividends and Interests (on savings or bonds)

• A notice of entitlement from a federal, state or private agency or corporation, or
• A copy of the benefit check, or
• A bank statement showing direct deposit of the benefit check, or
• A bank’s confirmation of direct deposit of the benefit check

Rental Income

• The previous year’s income tax statement, or
• Personal business records

Contributions

• A signed and dated statement from the individual(s) making contributions

No Income

• A signed and dated statement from the individual(s) providing your support, or
• A signed and dated letter or referral from a social service agency or institution providing financial or in-kind support