“Serving Those In Need Since 1982”
Basic Clinic Information – Hampton Roads Ecumenical Lodgings and Provisions, Inc. Information
New patients may return these documents (all of the documents) to the main office: Monday and Tuesday between 9:00 a.m. – 12:00 noon
Documents will not be accepted after 12:00 noon or on Wednesday, Thursday or Fridays.
Re-screening appointments are made on each Thursday of the month and the re-screening fee is to be paid at the time of the appointment.
- A W-6 form is required if you are unemployed. You may get this form at the Virginia Employment Commission (VEC),
- If you have no income all applicants are required to obtain a household support letter (available at the clinic). This form must be notarized. Applicants must return this document to the clinic and a current utility bill with the name and address of the person providing the support.
- Patient must not have any insurance to include MEDICARE, MEDICAID, dental, or private or veteran’s insurance.
- Valid Virginia drivers license or Virginia ID. Our services are for Virginia residents living within the close proximity of the clinic.
- Social Security cards for every member filed on current year tax form.
- Income for the person applying for services, and or every person on current year tax form. This includes pay stubs, records of tips, bonuses, commission, etc. must submit four (4) most consecutive pay stubsApplicants are required to bring a current year 1040 form along with their W–2. If you are self employed you will need a 1040 with the Schedule C. If you did not file taxes you are required to fill out a 4506-T form stating you did not file.
- Statement of any financial assistance or support for household to include supplemental security income, social security, unemployment compensation, pensions, settlements, Transition Assistance for Needy Families (TANF), Supplimental Nutrition Assistance Program (SNAP), child support, disability, retirement, alimony/ divorce decree, financial aid awards for college students. A bank statement or a letter from Social Security. All documents must be current.
Review or Download your Eligibility Requirements Checklist
- There is a $10.00 initial screening fee to be paid upon qualification. Patients will be re-screened every six months. It is the responsibility of the patient to make sure they call for a re-screening appointment.
- There is a $25.00 administrative fee for each dental visit. This fee must be pre-paid.