We would love to have you as a patient here at New Hope Clinic! We need to determine if you are eligible before your first visit, each year, and when your household situation changes.
DOCUMENTS TO TURN IN
1. Patient Forms
Forms to Complete & Return:
For your information:
NHC Clinic Schedule and Contact Information
NHC Patient Handbook
NHC Notice of Privacy Practices
2. Proof of who you are and that you live in Brunswick County. Bring in a document from two categories:
- Driver License
- State-Issued Identification Card from North Carolina Division of Motor Vehicles, another state, Puerto Rico, or a U.S. Territory
- U.S. Passport
- Work Visa
- Green Card
- Correctional System ID with photo
- A current rent, lease or mortgage payment receipt
- Two bank statements
- Current utility bill or hospital bill
(Document must be in the name of the applicant showing a Brunswick County address.)
A document showing that the applicant registered with a public or private employment service in Brunswick County
The Tax records of the applicant showing a current Brunswick County address (Ex. Form 1040, W-2, 1099, letter from IRS, property tax receipt).
A document showing that the applicant has enrolled his/her children in a public or private school or a child care facility location in Brunswick County.
A written declaration from an organization that has first-hand knowledge of the applicant’s intent to live in Brunswick County permanently, for an indefinite period of time, or residing in Brunswick County in order to seek employment or with a job commitment.
A document showing that the applicant is receiving public assistance (such as food stamps) or other services which require proof of residency in Brunswick County.
Official North Carolina school records, signed by school officials, showing current enrollment with a Brunswick County address (including secondary schools, colleges, universities, or community colleges).
A current North Carolina Motor Vehicle Registration Card in the applicant’s name and showing the applicant’s current Brunswick County address.
Records from a Health Department of other health care provider located in Brunswick County which show the applicant’s current Brunswick County address.
A document issued by the Mexican consular or other foreign consulate verifying the applicant’s intent to live in Brunswick County permanently, or for an indefinite period of time, or that the applicant is residing in Brunswick County to seek employment or has a job commitment.
A document from an employer or the Employment Security Commission verifying that the applicant has been employed in Brunswick County within the most recent six months, with a Brunswick County residence address listed
A current Voter Registration Card with a Brunswick County address
3. Proof of income. Provide all of the following documents that apply to your household.
- Last year’s Tax Return (e.g. Form 1040, 1040A)
- Current Social Security Benefits Award Letter
- Current Disability Benefits Award Letter
- Unemployment Benefits Award Letter, wage history
- Recent paystubs (at least one month, preferably two months)
- A wage form or written statement from employer indicating monthly income
- If self-employed, Income Tax Form 1040 & Schedule C. If no tax return, business records (income and expenses) for prior 6 months.
- Bank Statements (most recent statement; 6 months if self-employed)
- Written statement from absent parent/spouse or Clerk of Court showing child support/alimony paid or received for 6 months
- Documents showing any other income
- If no income, letter of support for person or organization supporting you
After turning in your application packet and documents, you will have a phone interview with a staff member to make sure that New Hope Clinic is the right fit for you.
Eligibility Volunteers are available to help on a walk-in basis:
• Boiling Spring Lakes: Mondays & Thursday 9:00 am – 4:00 pm
• Shallotte: Wednesday 1:00pm - 4:00pm
• Call 910-845-5333 for other times or for a phone interview, if needed