For the time being, we are making our clinic enrollment forms available for patients online. Current our prospective patients may print out the forms, complete them, and go through the interview process as usual with the intake nurse. Completing the forms before the enrollment appointment can help our team process you faster.

You must still bring all required intake documentation to your enrollment appointment, including:

1. Proof of Residence

    1. A utility bill
    2. A piece of mail with your name on it)

2. Income verification

    1. Payroll check stubs (two of the most recent for every working member of the household). If self employed, Schedule C
    2. Unemployment or Social Security verification documentation (cannot be a bank statement)
    3. Current verification of all other sources of income (child support, rental assistance, workers compensation, disability, alimony, pension & annuities, interest & dividends, financial assistance for living expenses)

3. Current tax information

    1. 1040 EZ (page 1)
    2. 1040 (pages 1-2)
    3. If self-employed, Schedule C (pages 1-2)

4. Other documentation to provide

    1. If you have applied for an insurance hardship exemption, please provide proof.

5. Must apply for BadgerCare/Medicaid

    1. Visit this website to complete the enrollment process.
    2. Please bring the letter of approval or denial that states your full name.

   

Please save any questions about completing the DOCUMENTS BELOW for the staff during your enrollment appointment.

   Flip through the tabs below to find the links for the documents that you will need for your enrollment visit. Please click links for both documents!