Reduced Eligibility Requirements (for Puerto Rican Evacuees only)
In order to qualify to be seen and treated at the Good Samaritan Clinic:
You must have fled hurricane Maria to arrive in Florida after Sept 1, 2017
You may not have health insurance applicable to your medical or dental issue
You may not be currently under treatment by any other clinic
You must prove that you currently reside in West Volusia County
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)
Your total assets must not exceed $5,000
You must be 18 years of age or older. We do not treat children
A fully-filled and signed recent version of our Puerto Rican Evacuee Good Samaritan Clinic application.
Or you may pick up an application from the clinic on Monday, Wednesday, or Friday, 3 PM to 7 PM,
Please completely fill out our application at home, and gather the few required documents. Remember, the
sooner you provide ALL required documents, the sooner you may make an appointment.
Proof of Identification:
A Puerto Rican photo ID
Proof of Residence in West Volusia County:
Choose one proof from those below showing that you live in West Volusia County
One utility bill with applicant name, address and date after Sept 1, 2017
One piece of mail with applicant name, address, and date after Sept 1, 2017
Report card for child registered in West Volusia school
Vehicle registration with applicant name and current address dated after Sept 1, 2017
A fully-filled and notarized Verification of Support (page 2 of this application)
Proof of Having No Applicable Health Insurance:
If you have ANY form of medical health insurance, you may not be seen here for medical issues.
If you have ANY form of dental health insurance, you may not be seen here for dental issues.
Proof of Income:
You must have total income at or below 200% of the federal poverty level to be seen here. Income includes wages, pension, retirement, disability, food stamps, financial support, investments, etc.
If any member of your household (applicant, spouse or partner) is employed, we require one recent pay stub.
If you receive financial support, we require a notarized Verification of Support, pg. 2 of our Puerto Rican application.
If you currently receive ANY other income, we require documentary proof.
Proof of Assets:
If you have bank accounts, we require one recent bank statement for 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 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
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?
We cannot accommodate everyone, so we limit our patients to those dwelling in West Volusia County who are of limited income.
How frequently must I qualify?
Just once. After April 1 of 2018 we will no longer treat Puerto Rican evacuees as special. You must then qualify under "normal" rules. See our web page on eligibility for "normal" rules.
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.
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. 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 live in West Volusia County.
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?
Don't worry - we'll just have you sign a statement that you have none.
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 only to obtain a letter from the Neighborhood Center at 434 S Woodland Boulevard in DeLand to show you are homeless.
I have Medicare or Medicaid or some other medical health insurance. What now?
Sorry, if you have ANY form of medical health insurance, you CANNOT be seen here for medical issues.
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.