Service Information

Who can become a patient ?

Eligibility

To be a patient at the Gloucester Mathews Free Clinic you must be: 

• A resident of Gloucester or Mathews County
• Over 18 years of age
• Uninsured
• Below 200% of the Federal Poverty Level
• Patient must not have any insurance to include Medicare, Medicaid, Private or Veteran’s 

What to bring to Screening 

Financials 
At your screening you must provide income 
documentation for everyone listed on your tax returns:

1. Four most recent consecutive pay stubs.
   
   

2. Most recent 1040 tax return and:

   • A copy of any W-2s, or 1099s 

   • If you are self employed your schedule C

   • If you did not file, you need to fill out a form 4605 T at your screening.
     
     

3. Proof of all other forms of income:

   • Unemployment Checks/Letter of Determination 

   • Child Support/Alimony Checks or Court 
     Decree

   • Social Security/Disability/Widow/ Widowers Benefits Letter

   • If unemployed, and not receiving unemployment benefits, you will need a friend or family member to complete our form, stating you are unemployed with no income and how expenses are being met.

   • Food Stamps Benefits Letter

   • TANF Determination Letter
     
     

4. Copy of driver’s license or state ID.

Remaining a Patient

Your Responsibilities

• Keep us informed of a working phone number.

• Show up for scheduled appointments, there are always people waiting to be seen. 

• More than two failures to show may result in your dismissal from the clinic.

• Be courteous to the staff; many are 
  volunteers

Emergency Room Use

• ER visits must be approved by the clinic or Ask-a-Nurse

• After all ER visits YOU must call the clinic for a follow-up appointment. This is YOUR responsibility.

• Excessive use of the ER may lead to being dismissed from the clinic.

Prescriptions

• Medications cost $3/month for each prescription

• Diabetic testing strips are $5/ month

• Allow 5-7 days for medication refills
   

Clinic Hours

New Patient Enrollment - Call (804) 210-1368 to set up screening appointment