New Patient Forms
Prior to your eligibility screening interview, please fill out the following forms. Click the button below to fill out the forms online or download the forms and email them to us. You can also print the forms and bring them with you to your appointment. Do your paperwork ahead of time.
General Eligibility Criteria
We provide medical, dental, pharmacy, and behavioral health services to adults who reside in Virginia (priority given to residents of Central Virginia), are uninsured, underinsured or have Medicaid, and who have income less than 250% of the Federal Poverty Level. Individuals are considered underinsured if their health insurance does not cover the medically necessary service they are requesting.
If you have Medicaid or Medicare, you may be eligible for our dental services. Educational classes are provided to all community members regardless of income.
Areas We Serve
In order to be eligible for a service at the Free Clinic of Central Virginia, you must have Medicaid or NOT have insurance for the service you are requesting. If you are a current patient and become eligible for Medicaid, we will continue to serve you.
You may not have a household income of over 250% of the Federal Poverty Level (FPL). For the purposes of eligibility, a household is defined as the patient and any adults or dependents listed on the patient’s federal income tax return. The following chart shows 250% of the FPL by household size for 2020:
Please bring the following documents to your eligibility screening interview:
Federal Income Tax Return (1040 Forms) for the Most Recent Year or a 4506-T Form if You Did Not File Taxes
Last 30 Days’ Pay Stubs for Any Employed Adults or Dependents Listed on the Tax Form (Including the Applicant)
Unemployment Benefit Award Letter (If Receiving Unemployment Benefits)
Current Notice of Action Letter for Food Stamps, TANF, and/or General Relief From Social Services (If Receiving Any of These Benefits)
Documentation of Social Security or Other Pension Benefits (If Receiving Any of These Benefits)
Current Virginia State Driver’s License or Virginia State Picture Identification Card (If You Do Not Have a Picture ID, We Can Help You Get One)
If you are living in a homeless shelter, transitional, or treatment program, a letter from the facility verifying resident status replaces the above documentation. You will be asked to provide income verification at a later date.
The Free Clinic of Central Virginia does not charge patients for medical, dental, pharmacy, or behavioral health services provided. We do, however, request that patients make a small donation between $5 and $10 for some services. Prescriptions are $3 each. No patient will ever be denied service or medications due to an inability to pay.
Services at the Free Clinic of Central Virginia are primarily provided by volunteer nurses, physician assistants, dentists, and physicians. Therefore, we are unable to provide certain services. These include examinations for disability determination if the patient is not receiving ongoing primary care from the Free Clinic of Central Virginia, obstetrics, routine family planning if the patient is not receiving ongoing primary care from the Free Clinic of Central Virginia, and medications not on our pharmacy formulary.