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APPLICATIONS

 

Self-Sufficiency Matrix


Check one box for each category below. Choose the answer that is closest to your situation.

 

By clicking the Submit button below, I hereby declare that the above information is true and correct. I know that any false information could jeopardize my eligibility to receive medical attention at Bethesda Health Clinic.

HOW TO APPLY

STEP 1
Meet Patient Eligibility Requirements

  • Low income adult (age 18-64)
  • Dental-only applicants can be 65+
  • Employed or perform an important unpaid job, such as being a caregiver, volunteer or participant in a self-improvement program (e.g. education, rehabilitation, etc.)
  • Uninsured or underinsured
STEP 2
Prepare Your Documentation

Scan or photograph the following documents and save them as JPG, PNG or PDF files. (Each file must be 2Mb or less in size.)

  • A current government-issued photo ID
  • A recent headshot
  • Your most recent paystubs
  • Pages 1 and 2 of your latest filed tax return (form 1040)
  • If 65+ and applying for Dental-only, your Social Security/Disability Awards letter
STEP 3

Complete and Submit All 4 Online Forms

  • Application for Medical/Dental Services
  • Medical History
  • Waiver of Liability
  • Self-Sufficiency Matrix
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