Annual Financial Assistance Application » Peoples Clinic

Financial Assistance

If you do not have insurance, that’s OK! We believe quality health care should be affordable to all. Complete our Financial Assistance Application.

Annual Financial Assistance Application

For this form in more languages, please Click Here.

You must meet minimum gross income requirements set by the Federal Poverty Guidelines to qualify for and receive financial assistance. Eligibility indicators are family income and family size. A family is defined as one or more individuals who are financially dependent as determined by the IRS.

We require verification of income for financial assistance. Refusal of an applicant to provide requested information will result in denial of financial assistance.

Financial assistance will not be granted if fraudulent information is given at the time of registration or on the Declaration of Income Form.

All third-party payments will be collected prior to providing financial assistance.

Financial Assistance applies to most medical and dental procedures. It does not apply to dental lab costs, court ordered services, or immigration documentation charges.

To DOWNLOAD an Annual Financial Assistance Application, please click here: English     Spanish     Bosnian    French

Doctor with Patient on Patient Portal