Become a Patient
Do I Qualify?
In order to be eligible for care at Western Tidewater Free Clinic, an individual must meet the following criteria.
Live in the Western Tidewater service area, which includes the cities of Suffolk and Franklin and the counties of Isle of Wight and Southampton, or Surry and Sussex Counties
Have no medical or dental insurance and not eligible for Medicare or VA benefits
Be an adult, age 18 or older
For the Clinic to be able to determine eligibility, prospective patients must have proof of 1) identification, 2) social security or tax identification number, 3) residency and 4) income.
PROOF OF SOCIAL SECURITY NUMBER OR TAX IDENTIFICATION NUMBER
PROOF OF RESIDENCY – personal mail is NOT accepted. Minimum = 1 of the following:
- Current bill dated within the past 2 months
- Other 1st Class mail dated within the past 2 months
- Letter from a homeless shelter (if you are residing in a shelter)
- Affidavit of residency if homeless – patient and witness will sign form at WTFC
PROOF OF INCOME – Minimum = 1 of the following – income must be provided for all persons listed on combined tax returns and/or contributing to household
- IRS Form 1040 Tax Return – PREFERRED
- One month of current consecutive pay stubs (if currently employed) – stubs must show pay period dates and gross amount earned for that period
- 1099 Form from last year only if self-employed or drew money from a savings fund
- Disability Letter (if on disability)/Social Security Letter (current year)
- Proof of pension and annuities (if you are receiving benefits)
- Unemployment Letter (if you are receiving unemployment)
- Completed Letter of Support (if unemployed and someone is providing you with a place to live or financial support)
- Affidavit of Income if unemployed – patient will sign form at WTFC
OTHER DOCUMENTS, IF APPLICABLE
- Medicaid Denial Letter (if you have applied and were denied)
- State of Virginia Medicaid card or MCO card (Optima, Anthem, or Virginia Premier)
Next Steps to
Becoming a Patient
2. Appointments for eligibility are not confirmed until ALL required documentation is provided.
3. Income must be provided for all members of your household. This includes anyone listed as a dependent on your tax return or anyone who has claimed you on a tax return.
4. Once you are certain you have all of the documentation, please call 923-1060 ext. 7004 to be pre-screened by the eligibility coordinator.
5. If you have all the correct paperwork, you will be given an appointment for eligibility.
6. After your eligibility appointment is completed, if you are determined to be eligible you will see a Nurse to complete a patient history and be given an appointment to see a Physician or Nurse Practitioner within 2 weeks.
7. Please bring all medications and a list of doctors’ names, addresses and phone numbers seen in last year.
8. If you need to cancel an appointment, it is necessary that you call 24 hours in advance. Clients that miss two appointments without a 24-hour notice may lose their service. If you do not call 24-hours in advance to cancel your appointment, a no-show fee of $10 must be paid before making your next appointment.
9. A $10 dental administration fee is due when a dental appointment is made.
10. Patient donations are welcomed ($5 per visit, $4 per 90-day prescription).
11. You must complete a new eligibility every 12 months to remain an active patient at WTFC.
The mission of Western Tidewater Free Clinic is to provide high-quality, non-emergency health care to the residents of Western Tidewater who cannot otherwise afford it. Western Tidewater Free Clinic maintains a 501(c)3 non-profit status and gifts are tax deductible to the full extent of the law.