Patient Application

NEW PATIENT APPLICATION AND ELIGIBILITY REQUIREMENTS

Genesis Community Health is a faith-based nonprofit clinic offering free medical, dental, and
mental health care, as well as social and spiritual support for those who qualify.

To become a patient:

• Applicants must not have any form of health insurance, including medical, dental,
  Medicaid, Medicare, or veterans’ benefits.
• Annual gross income of the applicant’s household must be at or below 200% of the
  federal income limit (see chart below). Gross income is all the money you make before
  taxes.

          200% or Less Gross Income 2026 Federal Poverty Guidelines

• All care given by Genesis is free of charge.
• You may choose to donate money or volunteer if you wish.
• Services offered by partner organizations may have associated costs if you don’t qualify
  for their financial assistance programs.
• It is very important that you work with these outside partner organizations’ financial service
  departments to receive financial assistance.

Please complete all sections and give required documentation to determine qualification
for care.

For each household member 18 or older, list annual income from sources below and attach supporting proof. If a source does not apply, enter “0.”