Patient Application

  • Does this look difficult? It is, but the clinic staff can help you fill it out. Bring your documents (listed below) and someone will be able to help you during clinic hours.

Want to be a clinic patient?  Stop by the clinic (Tuesday through Thursday, 8 a.m. to 4 p.m.) at 1116 12th Street, Bandera, Texas, to pick up a copy of the patient application to fill out at home.  Or download the form here.  If you would like help, please call the clinic and let staff know you would like assistance.  Si hablamos Español.

Once you submit your patient application, clinic staff will contact you and let you know if you qualify as a patient.  Remember the clinic can only see you if you live in Bandera County, have no health insurance, and meet some income requirements.

The patient application lists some supporting documents you need to bring to the clinic . . . please read the list carefully. 

     □ Texas driver’s license or Texas identification card (this is best!)

     □ Passport

     □ Or other photo identification

     □ Social security card or birth certificate

 

You must show some evidence that you live in Bandera County. Please bring in one of the following:

     □ Utility or other bill that shows your name and address

     □ Lease you signed with your landlord

     □ Bandera County tax statement

 

You will be asked about your income. Please bring in one of the following:

     □ Income tax return (most current—and this is the best to provide since you will need it if you want to participate in the Prescription Assistance Program)

     □ Four weeks of paycheck stubs (most current)

If you do not have a current income tax return or paycheck stubs, you need to bring in all of the following that you have:

     □ Social security check or bank statement if you have direct deposit

     □ Unemployment award letter or print out from Texas Workforce Commission

     □ Food stamp verification letter

     □ Other proof of income (spousal support or rental income)

 

If you were a patient last year, please bring in:

     □ Income tax return (most current)

     □ Four weeks of paycheck stubs (most current)

 

If you have changes during the year, please let the clinic know about a change in:

     □ Income

     □ Number of people you live with

     □ Where you live

     □ Health insurance status (if you have health insurance from any source)

 

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    MHM

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