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 150% at or below the Federal Poverty Guidelines and be an Alamance County resident. Below is a checklist of the requirements to become a patient:

Required Information

ALL information below is required to be seen at the Open Door Clinic. Upon receipt of ALL requested information, you will be notified of your appointment date. You have 30 days to return the documents below. Once you have reached your 30 days, we will no longer hold your application and you will have to start the application process over again.

 

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 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.

 

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.

 

③      Taxes

 

   _____          Current Federal Tax Return (1040) if you filed or 4506-t Form signed.

 

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

 

We must have your previous medical records to process your application.

Please complete a Consent for Release of Information for each provider you have seen in the last 5 years.

Form Downloads

New Patient Checklist

Application Form

Consent for Release of Medical Information

4506 IRS Request for Tax Return

 

Clinic Schedule