PREQUALIFYING FORM
Check the box that most applies to you.
I am uninsured.
I am an individual making less than $31,255 a year.
My partner and I are making less than $42,275 a year.
My family of four makes less than $64,375 a year.
None of these apply to me.
Yes, you are eligible to get care.
Please contact us if you have any questions about setting up an appointment.
Sorry, you are not eligible to get care.
Please contact us if you have any questions about getting medical care in the community.