To qualify to be seen at the medical clinic, call 386-738-6990 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 the medical clinic by applying personally during normal days and hours of operation. Or, another alternative, you may click either medical application or Spanish medical application to display and print the medical clinic qualifying form by using the "Print this page" button at the bottom of that display. You can return to this page by clicking the "Go back" button, also at the bottom of the display.

To qualify to be seen at the DENTAL CLINIC ONLY, you must first acquire the online qualification packet. Click dental application to display and print the dental clinic qualifying form. Use the "Print this page" button at the bottom of that display. You can return to this page by clicking the "Go back" button, also at the bottom of the display. Fill out the application, then call the dental clinic at 386-218-5977 to schedule an appointment for review of your paperwork. Dental staff will call to schedule an appointment.

If you submit a medical clinic application and are subsequently qualified for medical treatment, you need not re-qualify for dental treatment. However, if you submit a dental clinic application and are subsequently qualified for dental treatment, you must also submit a medical clinic application and be qualified in order to be seen at the medical clinic.

To be seen at the medical clinic you must have no insurance, be at or below 200% of the federal poverty level, and be a resident of West Volusia county. A financial calculator is provided below for your convenience.

To be seen at the dental clinic you MAY have medical insurance, but MAY NOT have dental insurance, and must be at or below 200% of the federal poverty level, and must be a resident of West Volusia county.

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 initially and annually the following proofs that you meet identification, residency, and income requirements:

IDENTIFICATION

• Birth certificate OR social security card for each member of household
• Driver's license OR state identification card OR Florida farmworker's card OR alien's registration green card with picture ID and correct address proving residence in West Volusia county

PROOF OF RESIDENCY

• Three consecutive months of any utility bill showing service at address claimed plus housing lease/rent/mortgage receipts for three consecutive months OR proof of ownership if you own your own home OR a shelter verification form from an approved social service agency OR a verification of support form signed and NOTARIZED by the person supporting you OR a property tax bill OR official mail received by you at the West Volusia address you claim

INCOME

• Proof of gross earnings within last eight weeks (either pay stubs or income verification form) OR income verification from your employer OR bank statements for the previous three months (all pages) OR unemployment/workers compensation statement or benefit stubs OR most recent federal tax return (all pages and W-2 forms) OR if unemployed, a notarized letter from someone who knows you but does not live with you OR if you are self-employed, three months of bank statements for all business accounts
• In addition to the above, if you receive any benefits such as child support, alimony, or social security benefits for you or any member of your family living with you, or any pensions or retirement benefits or interest, bring proof with gross amount
• If you are homeless: we will qualify you on a case-by-case basis