Becoming a Patient:
 

To qualify to be a patient with Good Samaritan Clinic, you must:

• Be between the ages of 19 and 64

• Live in Tuscaloosa, Greene, Pickens, Hale, Bibbs, Fayette, or Sumter counties

• Have no health insurance 

• Have a household income at or below 200% the federal poverty level

 

Patients must provide the following documents

• Photo ID (may be Driver’s License, but cannot be expired)

• Valid phone number/email address

• Address verification document (may be a bill or personal; must receive through US Mail)

• Medicaid Denial letter from Health Department

• Income Tax Returns for the previous year (if filed)

• Proof of income for applicant and household members

  • Social Security, SSI or SSDI Benefit Award Letter

  • Unemployment Notice of Determination

  • Alimony, child support or pension check

  • If employed, one month of income

                        Paid weekly:four (4) most recent pay stubs

                        Paid biweekly:two (2) most recent pay stubs.

                        Paid Monthly: last pay stub received

           

Documents may be provided to us in the following ways:

• Mail to Good Samaritan Clinic, 3880 Watermelon Road, Suite A, Northport, AL 35473

• Fax to 205-391-2718

• Email: goodsamclinic.eligibility@gmail.com

 

Once the clinic has received all the above documents, we will call you for an eligibility appointment.

 

We require our patients to RENEW their eligibility each year by submitting the above documents to us.

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Patient Forms:

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Please click to access our Patient Agreement and our Notice of Privacy Practices.