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New Patients

We know how hard it is to be without medical or dental care. That’s why we’re here. 

New Patient Qualifications

To qualify as a patient, you must bring the following information to a Financial Screening at one of the posted times listed:

  1. Picture ID

  2. Social Security Card

  3. Proof of income for everyone in the household, totaling one month. (This includes unemployment, disability, social security, etc. Bring the award letter or if direct deposit, bring a copy of the bank statement showing the deposit.)

  4. Proof of Food Stamps (bring the award letter)

  5. Proof of Residency (a utility bill or bring a letter from the responsible person if the utilities are in someone else’s name.)

  6. Medicaid Denial Letter (You must go to the Department of Family and Children Services in your county and apply for Medicaid. Even if you do not qualify, we must have a Medicaid Denial Letter, which will be mailed to you after applying.)

  7. Last Year’s Tax Return (if you filed)

  8. List of ALL Medication(s) and Dosages(s)

Financial Screenings

Financial Screenings:

Tuesdays, 2:00 PM – 4:00 PM
or By Scheduled Appointment

 

Temple Clinic:

253 East Highway 78
Temple, GA 30179

770-562-4501
info.raphaclinic@gmail.com

New Patient Applications

Please return your completed application to Tracey Hampton at tracey.raphaclinic@gmail.com or bring the completed application by the clinic. You may also mail it back to us.

 

You can download the application here.