Columbia County Volunteers in Medicine Clinic, Inc. MEETING THE NEEDS OF THE UNINSURED 310 East Third Street  P.O. Box N Mifflinville, PA  18631 570-752-1780               570-752-1786 (fax)

Eligibility Checklist

1. Proof of Residence (Driver’s license, utility bill, rent receipt, etc.)
2. Proof of income (all sources such as:  employment, self-employment, unemployment, compensation, Social Security Income, Social Security Disability Income, veteran’s benefits, welfare, child support, etc.)
3. W-2 Form for most recent tax year
4. 1040 Form (can be obtained by calling 1-800-829-1040)
5. Medical Assistance denial letter (if applicable)

Please mail, FAX, or bring in all information to:
                                                       Columbia County Volunteers in Medicine
                                                        P.O.Box N
                                                       310 East Third Street
                                                        Mifflinville, Pa 18631