To qualify for either medical or dental treatment, call 738-6990 to leave your name, address, and telephone number on voicemail. You will be sent a qualification packet. Alternatively, you may pick up a qualifying packet at either the medical or the dental clinic by applying personally during normal days and hours of operation. Or, another alternative, you may Click here to display and print the qualifying form by using the "Print this page" button at the bottom of the display and you can return to this page by clicking the "Go back" button, also at the bottom of the display.

If you are qualified for one of either medical or dental treatment, you need not re-qualify for the other.

In order to qualify, we must be assured that you have no medical insurance and cannot afford such. Further, since everyone experiences changes in employment or income, patients are required to re-qualify annually or whenever your circumstances change. This requires that you produce for our inspection the following:

• birth certificate OR social security card for each member of household
• picture ID proving residence in Volusia county
• three consecutive months of any utility bill showing service at address claimed
• current rent receipt OR mortgage statement with street address OR a shelter verification form. If you own your own house, we require proof of ownership
• proof of gross earnings within last eight weeks, either pay stubs or income verification form
• bank statements of all accounts held for most recent three months
• most recent federal tax return, all pages and W-2 forms
• if you are self-employed: notarized letter stating last three months of gross earnings and business expenses, including copy of most recent federal tax return for the business
• if you are not working: notarized letter stating you are unemployed from someone who knows you but does not live with you
• if you have no source of income: notarized letter from person assisting support of you and your family
• if you receive any benefits: bring proof with gross amount
• if you are homeless: we will qualify on a case-by-case basis