In order to qualify to be seen and treated at the Good Samaritan Clinic:
You may not be currently under treatment by any other clinic
You must have resided in West Volusia County for 3 months (if homeless, 1 month)
Your total income must be at or below 200% of the federal poverty level
(Click here to download the federal poverty guidelines for various household sizes)
You must be 18 years of age or older. We do not treat children
A fully-filled and signed recent version of our Good Samaritan Clinic application.
You may download the recent version of our application in English here anytime.
In order to print it on a PC, hold down the Control key and depress the P key. In order to print it on
a Mac, hold down the Command key and depress the P key.
Or you may pick up an application from the clinic on Monday, Wednesday, or Friday, 3 PM to 7 PM,
Or you may call (386) 738-6990 anytime to leave your name and address to receive an application by mail.
Please completely fill out our application at home, and gather the required documents. Remember, the
sooner you provide ALL required documents, the sooner you may make an appointment.
Proof of Identification (required; applies only to applicant)
A valid photo ID AND either a social security card OR birth certificate
Proof of Residence in West Volusia County (required; applies only to applicant)
Choose 2 proofs from those below showing that you have lived at your current address for 3 months
Verification of Rent, our application page 5 (need not be notarized)
3 consecutive recent months of dated mail (date-stamped envelopes are acceptable)
Valid vehicle registration
3 consecutive recent months of dated rent/mortgage receipts
Deed to home
Most recent property tax bill
3 consecutive recent months of dated utility bills (may be different utilities)
Recent report card or other document from child in West Volusia school
USPS change-of-address form 3 months old changing to your current address
If homeless, need ONLY registration letter from Neighborhood Center
Proof of Having No Health Insurance (required; applies only to applicant)
We require proof of your having applied for Medicaid. (An ACA application satisfies this requirement.)
We require the Letter of Determination from the Affordable Care Act (ACA, Obamacare). There is no cost.
If you have ANY form of medical health insurance, you may not be seen here.
Proof of Income From Any Source (required; applies to your entire household)
You must have total income at or below 200% of the federal poverty level to be seen here.
If any member of your household is employed, we require 8 consecutive recent weeks of pay stubs.
If you filed federal income tax for the most recent year, we require a copy plus your W2 statement.
If you receive financial support, we require notarized Verification of Support, our application page 6.
If you receive ANY other income, we require recent documentary proof.
Proof of Assets (required; applies to your entire household)
If you have bank accounts, we require the 3 most recent consecutive bank statements of each.
If you own properties other than your current address, we require to know the state and county of each.
If you own more than one vehicle, we require to know the year, make, and model of all your vehicles.
If you own ANY other asset, such as stocks or bonds, we require documentary proof of each asset.
Submission of application and documents
You must submit your application and required documents in person between 3 PM and 7 PM on
Mondays, Wednesdays, or Fridays to a qualifier. Allow at least one hour for your qualification interview.
We do not accept or acknowledge applications or required documents submitted by mail, email, fax, or drop-off.
Please do not telephone to learn if you are qualified - you will be informed by letter within a few days of
Patients must requalify each year. The reason is that life changes occur for each person - people move,
change jobs, marry, have children, get new driver licenses, etc. Requalifying is just like initial qualifying.
Frequently Asked Questions
How much will treatment cost me?
It will cost you nothing. We have no way of accepting money from you. All of our doctors, dentists, nurses, and staff are volunteers. Medical and dental treatment is free. Medication provided by us is free. Medication from WalMart or Publix is sometimes free, and if it is not, the charge is usually small. Some lab work is free, but some lab work you may have to pay for.
Why do I have to qualify before I can be seen?
Since your medical or dental treatment is free of charge to you, those who are paying for it wish to be certain beforehand that you cannot pay for it yourself.
How frequently must I qualify?
You must qualify initially to make an appointment, since we are not a walk-in clinic. Your qualification is good for one year. After that, you must qualify each year, since life circumstances change. You may, for example, get married, move, get new employment, or have a child. Such a life circumstance change may affect your qualification.
When must I qualify?
You may interview PERSONALLY with a Qualifier any Monday, Wednesday, or Friday between the hours of 3 p.m. and 7 p.m. No appointment is necessary for qualification. Do not fax, email, mail, or drop-off your application or documents.
You say certain documents are required. What documents?
You will need a fully-filled and signed application, a photo ID, and a social security card or a birth certificate. You will need two proofs from our list (see the application) to show that you have lived within West Volusia County for three months. You will need a Letter of Determination to prove you have applied for the Affordable Care Act (ACA, Obamacare), but this costs nothing. If you receive food stamps, you will need proof. If you have a bank account, you will need three recent consecutive months of bank statements. If you filed personal federal income tax for the most recent year, you will need a copy with your W2 statement of earnings. You will need 8 recent consecutive pay stubs for each employed family member. If you have income from any other source, such as disability, you will need proof of that income.
I'm worried that maybe we make too much money.
Not likely. In order to make too much money, your household would have to earn a lot from employment, or from retirement, or pension, or disability, or maybe have an extra property or an extra expensive car. Count up how many in your household, and then see our table of Federal Poverty Guidelines to learn if you make too much money.
I don't live in West Volusia County. How about me?
Sorry, but we only see patients who can prove they have lived in West Volusia County for the last three months.
I live in Daytona Beach. That's Volusia County, isn't it?
Sorry, that's East Volusia County, so we can't see you. There are other clinics in your area.
I don't have a bank account. What do I do?
If you don't have a bank account, don't worry - we'll just have you sign a statement that you have none.
I didn't file taxes. What do I do?
If you haven't filed personal federal income taxes, no problem. We'll just ask you to sign a statement saying you haven't.
How long and how many visits does all this take?
Your interview with a Qualifier will take about an hour. Most applicants provide all the required documents in one or two visits. If your Qualifier says you qualify, you can make an appointment before you leave.
Who is considered to be in my family or my household?
We consider a family or household to consist of the applicant, a spouse or partner of the applicant, and any minor children for whom the applicant is responsible. We do not consider parents, grandparents, adult children, brothers, sisters, aunts, uncles, fiances, friends, boarders or lodgers to be part of the applicant's family or household.
I'm homeless. What about me?
If you are homeless, you need not provide two proofs you have lived in West Volusia County for three months. You need only to obtain a letter from the Neighborhood Center at 434 S Woodland Boulevard in DeLand to show you are homeless. Also, you don't have to apply for the Affordable Care Act, but you do need documentary proof you've applied for Medicaid.
I have Medicare or Medicaid or some other medical health insurance. What now?
Sorry, if you have ANY form of medical or dental health insurance, you CANNOT be seen here.
I'm qualified, and I have an emergency.
If it's Tuesday, Thursday, Saturday, or Sunday, you may want to go to the Emergency Room at the hospital for a severe emergency. Otherwise, call (386) 738-6990, and explain your emergency, and we'll try to see you as soon as possible.
I'm not qualified, but I have an emergency - perhaps a really bad toothache or maybe a burn.
If it's Tuesday, Thursday, Saturday, or Sunday, you may want to go to the Emergency Room at the hospital for a severe emergency. Otherwise, call (386) 738-6990 and MAYBE we can see you this one time on an emergency basis - no guarantees. It depends on the nature of your emergency and whether we have a dentist or doctor available. But if we do see you, you must promise to qualify completely just as soon as you can.
Telephone: (386) 738-6990 (24/7 Voicemail)