Memorial Primary Care Centers Eligibility Requirements
Please find below a list of required documents that must be presented on the day of eligibility. Please make every effort to have all documents available, as a Primary Care Center Identification Card cannot be issued until eligibility is established. Feel free to contact us with any questions at (954) 985-1551.
Proof of Address:
Please provide a current utility bill such as FPL, Telephone, Gas, Water, Cable, or Satellite TV. The bill must show your name and address. If the utility bills are not in your name, you must bring a notarized letter from the person whose name is on the bill along with the current utility bill. The notarized letter must state that you live at the address on the bill. Other acceptable proofs of address include a Voter’s Registration card, or a Lease Agreement.
Proof of Income:
- If married, spouse’s income is required. Please provide consecutive and complete paycheck stubs for your last 6 weeks of employment. If you are an unmarried parent, you must provide your children’s other parent’s income for the same period. If you cannot provide pay stubs, you must obtain a dated letter from your employer, on company letterhead, stating hours worked and your Gross Pay. If you are not legally divorced, you must provide your spouse’s income.
- Unearned income includes AFDC, Alimony, Child Support, Disability Income, Social Security Income, Unemployment Compensation, and Pensions.
- If you do not have documented income, and are being supported by another person, you must provide a notarized Letter of Support from the person who is helping you. This letter cannot be older than 30 days, and must state how long the person has been supporting you.
Current Income Tax Return:
You must bring all pages of your most recent tax return, including W-2 forms, 1099’s and all schedules. If married filing separately must present both tax returns. If you do not have a copy of your tax return, you may call 1-800-829-1040, to request a copy.
Bank Statements:
Please provide the last 3 consecutive bank statements for all of your bank accounts, including those for which you are a joint owner (Checking, Savings, CD’s, Money Markets accounts, etc.) . Important: On-line statements are not acceptable. Must be a validated printout from the Bank.
- If you do not have a checking or savings account, please bring proof of how your bills are paid. Examples would be copies of Money Orders, cash receipts, cancelled checks for the last 3 months.
Picture Identification Card:
Florida Driver’s license, Florida State ID, Valid Passport, Resident Alien card, Employee picture ID. The address on your identification must be current, if you do not have a utility bill in your name.
Social Security Card:
A Social Security card must be presented for each member of the household. If your Social Security card has been lost or stolen, you must provide proof that you applied for a duplicate copy.
- Employment authorization card or Green Card
- If you do not have a Social Security number, please bring your passport and I-94 card
Medicare:
If you have Medicare, or will be eligible for Medicare, please bring the card or the information stating when you will be eligible.
Medicaid:
If you have applied for Medicaid already, you must provide proof of the application. (Yellow HRS 2066 form). If you have not applied for Medicaid prior to coming to the Primary Care Center, please bring all names, dates of birth, and Social Security numbers for everyone living in your household.
Proof of Legal Guardianship: (If applicable)
If you are a legal guardian, you must provide us with the proper custody or legal documents.
Additional Information and or documentation may be requested to complete your application. All information is subject to verification. Providing false information may result in the denial of any type of financial assistance through the South Broward Hospital District d/b/a Memorial Healthcare System.