Patient Requirements

Eligibility Requirements

Services are based on a sliding fee scale.

Cost of Services/Eligibility

Services are provided at an affordable rate to qualifying uninsured, underinsured, and homeless persons with limited income. Picture ID, proof of income, and verification forms (homeless) are required at the time of service to determine eligibility.

Eligibility is based on household income. Patients must bring ONE of the following to the center to determine if they are eligible for a sliding fee discount:

  • Current year’s tax form (1040 form)
  • One month of current pay stubs
  • Unemployment stub
  • Notarized letter from employer on letterhead that states your salary or wages
  • Fixed income statement (example: pension, social security, or bank statement showing deposits)
  • Signed and notarized personal letter verifying financial status, housing situation, and how you cover expenses
  • Letter on agency letterhead verifying financial status (example: Housing Authority)
  • Office of Public Assistance benefit printout (example: TANF, Emergency Financial Assistance)
  • WG15 (Georgia Department of Labor)
  • If you are self-employed – tax forms from the current year and a profit and loss statement

We do not deny services based on a person’s:

  • Race
  • Color
  • Sex
  • National Origin
  • Disability
  • Religion
  • Sexual Orientation
  • Inability to Pay

We accept Medicaid, Peach Care, Well Care, AmeriGroup, Cash, and Credit Cards. No personal checks.

Patient Forms

Patient Intake Packet
Consumer Rights
Eligibility Requirements
Informed Consent
Notice of Privacy Practices
Out-Patient Service Orientation
Notice to Service Patient
Sliding Fee Verification Form
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