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Mother of Mercy Free Medical Clinic

How to become a clinic patient

Learn how you can become a patient of the Mother of Mercy Free Clinic.

Patient Eligibility Criteria

In order to apply to become a member of the clinic, all prospective patients must schedule and complete an Eligibility Appointment to review eligibility criteria prior to being seen by a physician.

Please call the Appointment and Intake Line at 703-335-2779 to schedule your screening. There are no same day doctor visits at this time. You must bring all documentation with you at the time of your financial screening.

Please bring the items listed below to your Eligibility appointment:

Income Verification:

Patient’s household income must be at or below than 200% of the Federal Poverty Level. 

Click Here to view the current income limits

  • No insurance or underinsured
  • Provide the clinic with the most recent paystubs for patient and spouse/partner
    • Last 4 if paid weekly
    • Last 2 if paid biweekly
  • If paid cash (patient and/or spouse/partner):
    • Have employer complete the Income Verification Form from the Forms section below
    • Bring a letter from employer stating hours and pay rate on Employer Letterhead or notarized.
  • SSI letter or last bank statement showing SSI deposit for patient and/or spouse/partner.
  • Disability, unemployment, pension letters for patient and/or spouse/partner.
  • If currently not employed and support is provided by family or friend. Have family or friend
    complete the Affidavit of Support Form located in the Forms section below.

Residency Verification:

Must be a resident of Western Prince William County (Nokesville, Bristow, Gainesville, Haymarket),
Manassas City, or Manassas Park

  • You must provide the clinic with one of the following:
    • State Issued Identification
    • Bill (utility bill or other bill)
    • Official Documents (Food Stamps letters, School letters, Vehicle Registration)
    • Current Lease Agreement
    • Bank Statements

Identification:

  • Bring a picture ID (this can includes a passport or government issued ID)

Taxes:

  • If you provide the prior year’s income taxes, you will be approved for a 12 month membership.

Forms 

Eligibility Requirements