Can I be a patient?

In order to be a patient of the Open Door Clinic you must 18 years of age or older, gross 250% at or below the Federal Poverty Guidelines based on your household income and be an Alamance County resident. Below is a checklist of the requirements to become a patient.

Required Information

Please complete the intake application forms and submit one item from each category below if pertaining to you:

 

Category 1: Verification that you or the person you live with is an Alamance County resident.

PO Box is not acceptable since this does not indicate your physical address.

• Current North Carolina driver’s license or picture ID. No out of state IDs accepted.

 

• Current utility bill such as water, cable, electricity, natural gas or land line telephone bill, etc. DATED within last 30 days.

 

• If you live in Liberty, Mebane or Gibsonville we will need an Alamance County tax bill, car registration or Food Stamp award letter DATED indicating your PHYSICAL address.

 

• If you live in a group home or shelter, please provide a statement from that facility indicating that you are currently residing there.

 

• If you DO NOT have any of the above documents, we will accept a Food Stamp Award letter.

 

• If you DO NOT have any of the above in your name, a notarized statement from the person you live with and their utility bill or food stamp award letter will be accepted.

 

Category 2: Proof of Household Income

• Your two most recent pay stubs if you are working, verification of gross unemployment benefits, verification of child support, pensions, retirement, social security or disability checks.   Current bank statements showing direct deposits of benefits is acceptable.

 

• If you filed taxes or you are listed on taxes with a spouse, parent or other family member, all family members receiving income will need to turn in their recent income as listed above.

 

• IF you have NO income:  Provide a NOTARIZED statement from the person that supports you.

 

Category 3: Taxes

•  Current Federal Tax Return (1040) if you filed.

 

Submitting Completed Applications

All forms and supporting documents are required at the time the application is submitted in order to be considered complete.  Completed applications and supporting documents may be emailed to [email protected] or submitted in person at Open Door Clinic during clinic hours.

An appointment will NOT be made until the application and ALL supporting documents are turned in.

 

Form Download

Intake Application: ODC Intake Application

Need a letter of support? Use this form: Letter of Support Form

Open Door Patient Quick Reference Guide: ODC Patient Reference Sheet

Have you been seen by a doctor outside the Cone Health network? Please complete our Medical Record Release Form so we can obtain your records:  Medical Record Release Form

 

 

Clinic Schedule