Eligibility Application Forms:
Those who wish to receive medical services at Mercy Health Clinic are first required to visit the Clinic for an interview to determine if the person meets all of our eligibility criteria:
- 18 years of age or older
- resident of Montgomery County
- no health insurance (including Medicaid or an ObamaCare exchange plan)
- low or no income (total annual income of 250% or less of the poverty level – see below for more details)
Eligibility interviews are conducted at Mercy Health Clinic each week on Tuesdays and Wednesdays and Fridays from 9:00 AM to 12:00 PM. Interviews are on a first come, first served basis.
New and current patients of Mercy Health Clinic MUST re-qualify every year.
Suggested documentation to bring to the eligibility interview:
- proof of residency in Montgomery County. This could include one (1) of the following: utility bill with name and address, mortgage or lease, property tax bill, school records, driver’s license with current address, Maryland State ID Card, signed federal tax return / W2 (current year), recent pay stubs with name and address, written statement on letterhead from homeless shelter, official County or State correspondence on letterhead, letter from landlord/third party host with host’s proof of residency.
- proof of age, if possible. Picture ID is preferred. Driver’s license, birth certificate or passport will be accepted as proof of age.
- proof of income. This could include one (1) of the following: most recent pay stubs, most recent signed federal tax return, letter from employer on company letterhead stating gross income per week or per month, disability statement/unemployment statement, social security/SSI award letter, court statements about alimony or child support, letter from a relative or friend that states the amount of support provided to the patient – letter must be signed with the address and phone number of the person writing the letter. If the applicant has no income: please bring a signed letter from the applicant, family member, professional or other that states the person has no income; or bring a letter from employer indicating termination of employment.
Below are the income eligibility requirements of Mercy Health Clinic. These represent 250% of the Federal Poverty Guidelines for 2014.
Please note that the federal Poverty Guidelines are determined each year by the U.S. Department of Health and Human Services and are published in the Federal Register: they are not determined by Mercy Health Clinic.
# of persons annual income at Federal Poverty Guidelines
in the family 250% of poverty level 2017 poverty level
1 person: $30,150 or less $12,060 or less
Family of 2: $40,600 or less $16,240 or less
Family of 3: $51,050 or less $20,420 or less
Family of 4: $61,500 or less $24,600 or less
Family of 5: $71,950 or less $28,780 or less
Family of 6: $82,400 or less $32,960 or less
For each additional $10,450 $4,180
If we determine a person may be eligible for Medicaid, we will assist the person with the Medicaid application and enrollment process. If we determine a person may be eligible to receive a subsidy for a qualified health plan on the exchange (e.g., ObamaCare), we will refer the person to a Navigator who can assist with the application and enrollment process.