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APPLICATIONS

 

Waiver of Liability

Waiver of Liability for Treatment

The Medical/Dental treatment provided by Bethesda Health Clinic, a charitable non-profit organization (the “Clinic”), is provided by volunteer healthcare providers who do not receive compensation.

Texas Law (Texas Charitable Immunity and Liability Act of 1987 [as amended]), as well as Federal Law (Volunteer Protection Act of 1997), provides IMMUNITY FROM CIVIL LIABILITY for any act or omission resulting in death, damage, or injury if the volunteer was acting in good faith and in the course of his/her duties or functions within the organization.

By signing below, you acknowledge: (1) that the Clinic’s volunteer healthcare providers (such as physicians, physician assistants, registered nurses, licensed vocational nurses, pharmacists, podiatrists, dentists, dental hygienists, optometrists, or any such persons who are retired or otherwise defined or included under Texas law or Federal law) are providing health care that is not administered for or in expectation of compensation; and (2) that there are limitations on you or your family’s ability to recover damages from the volunteer or the Bethesda Health Clinic in exchange for your receiving health care services.

It is intended that this WAIVER be as broad and expansive as allowed by law.

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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