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, you must bring in the required information below with the application to have an interview with us to determine if you can get approved for our services.

• A current Florida Driver’s license or identification card with a Pasco County address
•  Proof of residency if ID provided does not reflect a Pasco County address
• Original Social security card or birth certificate or US passport or voter id or green card
• Proof of household income, last year’s federal tax return or W2s, last 3 consecutive paystubs or last 3 bank statements for all members of the household
• Additional Income- documents related to other household income such as pension statements, SSI, SSDI or food stamps must also be presented.
• Notarized letter from homeowner if patient is living there temporarily
• If homeless- please provide updated address from DMV or seek letter from the Homeless Coalition
• Applicant cannot hold current health insurance- this will be verified by staff.

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