Mercy Medical Clinic and Foundation

A Volunteers in Medicine Community Clinic
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DOVE HUNT

New Patient Financial Requirements

If you or your spouse is currently working, we need:

  • Pay stubs from the pay 30 days.

 

If you or your spouse filed income taxes for the previous year, we need:

  • A copy of your federal income tax return.  If you can't find your tax return, the IRS will send you a copy by calling 1-800-829-1040.

 

If you or your spouse is on unemployment, we need:

  • Unemployment pay stubs from the past 30 days.

 

If you or your spouse is on Worker's Compensation, we need:

  • A copy of the Worker's Comp income.

 

If you or any adult member of the household gets Social Security, we need:

  • A "Notice of Award" letter.  If they don't have one, their local SS office will provide a letter stating the date you became eligible and what types of benefits are being received.

 

If you or your spouse receives food stamps, we need:

  • A Food Stamp letter that includes the monthly amount received.

 

If you are unemployed, we need:

  • Verification of unemployment.  The patient must go to the Department of Labor to get this form.  The Vidalia DOL's phone number is 538-3231.

 

We also need a photo i.d.

 

 

 

 

 

 

 

 

 

 

 

Size of FamilyGross Annual Family IncomeWeekly Income
1$21,660 $416/wk
2$29,140 $560/wk
3$36,620 $704/wk
4$44,100 $848/wk
5$51,580 $991/wk
6$59,060 $1135/wk
7$66,540 $1279/wk
8$74,020 $1423/wk
For each additional family member, add $3,740 to the gross annual income.