Adult Pasco County residents up to age 65 who are uninsured and are ineligible for Medicaid can apply for services. The clinic does not treat patients who qualify for Medicare, Medicaid, VA, or have private/commercial health insurance.  Only routine (non-emergency) medical conditions are treated. Application and financial screening to meet eligibility requirements must be completed prior to receiving a medical or dental appointment. A $5 donation is requested from each patient for each visit.

Before you can be seen as a patient at the Good Sam Clinic, you must complete our Health Clinic application and our Patient Health History Form.

• English Forms:
  • Clinic Application – English
  • Patient Health History Form – English
• Spanish Forms
  • Clinic Application – Spanish
  • Patient Health History Form – Spanish

You can also get the application at the clinic.

APPLICATIONS MUST BE SUBMITTED IN-PERSON BY THE APPLICANT. MAILED, E-MAILED AND FAXED APPLICATIONS WILL NOT BE ACCEPTED!

In addition to the above application, please bring the following items/documents with you to complete your application:

1. Florida Driver’s License / Identification Card: Current with a Pasco County address – if your ID does not have your current address, you must provide documentation to prove that you are a resident of Pasco County. ( i.e. current Medicaid Denial Letter or Utility Bill)

2. Social Security Card – (We must see your card, not a copy).  If you have lost your card, please apply for a replacement card.  (When you apply for a replacement card, you will get a letter indicating that you have applied for a replacement. You may use that letter.)

3. Proof of Income (for Entire Household): All employers pay statements/proof of income for the last 3 pay periods (weekly, bi-weekly, or monthly). OR last 3 months of bank statements.  OR FEDERAL IRS TAX RETURN: Submitted last year for each member of the household. (Note: January through April 15^th, we will accept W-2’s prior to filing IRS tax returns. A copy of your tax return must be provided after filing.)

4. Additional Income: Documents relating to other household income including but not limited to pensions, SSI, SSD, Food Stamps (letter stating amount received) for each member of the household must be presented.

5. Current Medicaid Denial Letter if you have, otherwise you must apply asap. While proof of Medicaid denial is not mandatory to be seen by a healthcare provider at Good Sam, it  is mandatory for diabetics who will be taking insulin, all patients using inhalers and for most medications received through a Prescription Assistance Plans (PAP) regardless of  the health condition. 

HOURS TO SUBMIT APPLICATIONS:

MONDAY – THURSDAY:  10:00 am – 11:30 am and 1:00 pm – 2:30pm

APPLICATIONS MUST BE SUBMITTED IN-PERSON BY THE APPLICANT. MAILED, E-MAILED AND FAXED APPLICATIONS WILL NOT BE ACCEPTED!