Mother of Mercy Free Medical Clinics
Forms
How to become a clinic patient
Patient Eligibility Criteria
In order to apply to become a member of the clinic, all prospective patients must schedule and complete an Eligibility Appointment to review eligibility criteria prior to being seen by a physician.
Please call the Appointment and Intake Line at 703-335-2779 to schedule your screening. There are no same day doctor visits at this time. You must bring all documentation with you at the time of your financial screening.
Please bring the items listed below to your Eligibility appointment:
Income Verification
Patient’s household income must be at or below 300% of the Federal Poverty Level.
View the current income limits (PDF)
If currently not employed and support is provided by family or friend. Have family or friend
complete the Affidavit of Support Form located in the Forms section below.
- No insurance or underinsured
- Provide the clinic with the most recent paystubs for patient and spouse/partner
- Last 4 if paid weekly
- Last 2 if paid biweekly
- If paid cash (patient and/or spouse/partner):
- Have employer complete the Income Verification Form from the Forms section below
- Bring a letter from employer stating hours and pay rate on Employer Letterhead or notarized.
- SSI letter or last bank statement showing SSI deposit for patient and/or spouse/partner.
- SSI letter or last bank statement showing SSI deposit for patient and/or spouse/partner.
- Disability, unemployment, pension letters for patient and/or spouse/partner.
- If currently not employed and support is provided by family or friend. Have family or friend
- complete the Affidavit of Support Form located in the Forms section below.
Identification
- Bring a picture ID (this can includes a passport or government issued ID)
Taxes
- If you provide the prior year’s income taxes, you will be approved for a 12 month membership.
Forms
- Financial Eligibility Packet – ( English) ( Spanish)
- Affidavit of Support – ( English) ( Spanish)
- Financial Review – ( English) ( Spanish)
- Income Verification – ( English) ( Spanish)
- Notice of Privacy Practices – ( English) ( Spanish)
- Self Affidavit of Income – ( English) ( Spanish)
- Renewal Of Eligibility – (English) (Spanish)