Patient Requirements

New or re-newing patients must apply in person during clinic hours and bring the following proof-of-income information:

When applying to become a patient at Surry Medical Ministries, please bring proof of all forms of income for your household.

BRING ALL THAT APPLY TO YOU AND YOUR SPOUSE.

Examples:  

  • Most recent 2 paystubs
  • Bank Statement showing direct deposits of income (retirement, disability, alimony, veterans benefits, wirjerother)
  • Most recent award letter from Social Security
  • Child support award letter
  • Workman’s comp or unemployment benefits
  • Most recent award letter for food stamps monthly allotment  (Dept. of Social Services can provide this)
  • Any other sources of income or household support not mentioned here

If you are paid in CASH… print the attached form (or receive one at SMM during eligibility interview) and have your employer complete to confirm your rate of pay.

or

a patient may bring a copy of their complete tax return for the current year.

When applying to become a patient at Surry Medical Ministries, if you have no income, please bring any of the below items that apply to you:

  • Most recent award letter for Food Stamps monthly allotment  (Dept of Social Services can provide this)
  • Statements from any persons or organizations who provide support to you, include all temporary support:
  • Print and complete the bottom half of this form or you will receive a copy of this form at Surry Medical Ministries during your eligibility interview.