LORAIN COUNTY FREE CLINIC APPLICATION INSTRUCTIONS
3323 PEARL AVENUE, LORAIN, OHIO 44055
PLEASE READ CAREFULLY AND FOLLOW ALL INSTRUCTIONS OR YOUR APPLICATION WILL BE DELAYED
ATTENTION FREE CLINIC APPLICANTS:
PLEASE NOTE:
If you are on MEDICARE OR MEDICAID, you are NOT eligible for our program.Please call 440-233-0153 for information through the Family Care Center.
If you are on SOCIAL SECURITY DISABILITY, you are NOT eligible for our program.Please call 440-244-4150 or 1-800-808-2991 for information through Job and Family Services.
If you are a VETERAN, you will need to call the VA at 440-244-3833 for services.If you are denied services from the VA, please send in the denial letter from the VA WITH your Free Clinic application.If you were dishonorably discharged, please send in a letter from the VA with your Free Clinic application.
IF NONE OF THE ABOVE APPLIES TO YOU, PLEASE COMPLETE AND RETURN THE ENCLOSED FORMS TO LCFC 3323 PEARL AVE LORAIN OHIO 44055.
Fill in your name on top of the “Patient Statement” form, read and sign at the bottom.If you require someone else’s consent, have that person sign on the witness space.
YOU MUST SEND IN PROOF OF INCOME WITH YOUR APPLICATION.IF YOU DO NOT SEND PROOF OF INCOME, YOUR APPLICATION WILL BE DELAYED!!If you are employed, you need to show 2 current pay stubs.If you are self employed, please send in a copy of your most recent taxes along with your Schedule C.If you are not employed, provide a statement on how you are supporting yourself.
Explain as completely as possible ALL OF THE REASONS you need to see a doctor or a dentist on the last line of the Patient Information Sheet or attach a separate sheet of paper with your explanation.
Please call the Free Clinic (277-6641) no earlier than 5 days after your application has been submitted to find out if you are approved.
