Criteria and Application for Clinic

 (Applications at the bottom of screen)
(Archivo en español al pie de la página)

Patients are seen by appointment only AFTER verification of application. We do not take walk-ins. This is not an urgent care facility.

Eligibility Requirements:

1. Be without healthcare insurance and be ineligible for Medicaid or Medicare.
2. Be between the ages of 19-64 or until eligible for Medicaid or Medicare.
3. Have a TOTAL household income no greater than 200% of the Federal Poverty Guidelines (see chart).
4. Present a valid photo ID card.
5. Provide a Social Security Number.
6. Provide proof of income for all members of the household (pay stubs to cover the most recent month of income, W2 form, tax return, etc.).

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Information presented will be verified before acceptance as a patient at the Free Clinic of Meridian.

Federal Poverty Guidlines Chart

The application is provided in Document form as well as a PDF form. Select which one you wish to download, whether you have access to MS Word or Adobe Reader.

Click the appropriate link below to download the application to print, fill out, and bring to the clinic other required documents to apply for services.

When you fill it out, try to be as detailed as possible. Make sure you sign all areas where your signature is required.

If mailing or emailing please make a color copy of your valid photo ID, Social Security number, and any proof of income to include with your application. If you do not have income, please fill out the 'No Income Form', which is included on the last page of the document. If you do have income, disregard the last page. If you choose to bring in your application, we can make copies of your other required documents.

Examples of Income include the following:

• Salary or Wages
• Paycheck Stubs
• W-2 tax forms
• Income Tax Return
• Food Stamp Benefits (printout of monthly benefit from the benefits office)
• Social Security (annual letter of benefit or most current 1099-R)
• Disability
• Any other sources of income

Income requirements include Total income for the Entire household. 

Once we have all the required documents, we will submit your application for approval. Once approved, you will be contacted when an appointment becomes available. 

*Options for Submitting Application*

Mail Application to: The Free Clinic of Meridian
                                   P.O. Box 3724   
                                   Meridian, MS 39303     
*If mailing your application, make a copy, and attach a color copy of your photo ID and proof of income*. 

Scan a color copy of the application and Email Application to:  freeclinicofmeridian@gmail.com

Fax application to: ​601-286-5548

Bring Application in person (preferred): The Free Clinic of Meridian
                                                                      4707 Poplar Springs Drive
                                                                      Meridian, MS 39305

Download & print application!

No Income Form
File Size:	13 kb
File Type:	docx

Download File

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2022 Patient Application In English
File Size:	255 kb
File Type:	docx

Download File

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2022 Patient Application in Spanish
File Size:	520 kb
File Type:	pdf

Download File

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