You must appear in person with all your documents between 3 p.m. and 7 p.m. on Monday, Wednesday or Friday. No appointment is necessary. The interview will take from 30 minutes to an hour. Applications are available 3:00 - 7:00 pm on Monday, Wednesday, and Friday; by mail request or you can download and print an application here.

Before making a medical or dental appointment at the Good Samaritan Clinic, you must first qualify by proving the following through our application process with your documentation:
    1. You have lived in West Volusia County for 1 month or more
    2. You have no applicable health insurance
    3. Your household income does not exceed 200% of the Federal Poverty Level (FPL). You can download and print the FPL table here.
    4. Your household assets do not exceed $5000 or $6000, depending upon the size of your household.

Please see page 2 of our current application for the full list of required documents. Bring all your documents, a completed/signed application, and your photo ID. All these will be returned to you.

You are advised to read the application carefully and gather all requested documents before the interview. The sooner you provide ALL the requested documents, the sooner you may make an appointment.

Qualification is effective for one year. Re-qualification is just like initial qualification, requiring a new application and all the documents.

There are four ways to obtain our bilingual English/Spanish application:
    1. You can call 738-6990 to request a mailed application.
    2. You can pick up an application on clinic days after 3 p.m.
    3. You can pick up an application any time from our outside box at 136 East Plymouth Avenue in DeLand.
    4. You can download and print an application here.