PATIENT APPLICATION

If you believe you may qualify, it is best to apply for eligibility before you need care. Application packets are available anytime outside of the Clinic entrance at 401 Arnold Street NE, Cullman AL.
Or, you may choose to print the Eligibility Application from our website.

Please Note: you will need Adobe Reader on your computer or mobile device to open and view the above pdf file.
Get Adobe Reader for your computer. Get Adobe Reader for your mobile Device. Both these Adobe Readers are free of charge.

Completed applications are received from new patients during normal Medical Clinic hours on Monday, Tuesday, Thursday, and Friday from 8:00 to 12:00 and 1:00 to 4:00, and Wednesday from 8:00 to 12:00. Once we receive your completed application and no additional information is needed, we can make a determination of your eligibility with 24 to 48 hours. If you qualify, you will be mailed a letter, along with an appointment card if needed, notifying you of your acceptance.

Each year between January 1 and February 16, patients must reapply and pay an annual processing fee of only $20. This annual fee gives you access to healthcare services through Good Samaritan including the majority of your medications at no additional cost.

READ, SAVE OR PRINT APPLICATION FORM

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