Patient Forms
Our patients are people you see every day in our community – like the young cashier handing you your order at a busy ice cream shop, and the older gentleman counting your shirts at your neighborhood dry cleaner. Others work behind the scenes – like the dishwasher in a popular restaurant and the evening security guard at a local office building. Still, others have faithfully served their customers for years, working as a caregiver and cleaning homes. They work hard and are focused on doing a good job so they can provide for their own families. Most never thought they would ever need free health care.
All live within Polk County and have incomes at, or below, 200% of the Federal Poverty Level (for a family of 4, this is up to $4,417 per month). Most are parents with children who live at home.
Although most of our patients work, their jobs do not include access to affordable health insurance.
In recent years, an increasing number of new patients came to We Care of Central Florida after losing their job and their health insurance.
To be eligible for free health care services or other resource assistance, the gross household income (per household size) must be between 0% and 200% of the Federal Poverty (2024 Income Guidelines). The chart below outlines the annual Federal Poverty Level for each family size represents income levels that are commonly used as guidelines for health programs.
| Household Size | 200% FPL (Monthly) |
| 1 person | income up to $2,430 per month |
| 2 people | income up to $3,286 per month |
| 3 people | income up to $4,143 per month |
| 4 people | income up to $5,000 per month |
| 5 people | income up to $5,856 per month |
| 6 people | income up to $6,713 per month |
| 7 people | income up to $7,570 per month |
| 8 people | income up to $8,426 per month |
*For households with more than 8, add $5,140 for each additional person
English Forms
Applications are eligible for one (1) year from the date of approval.
Below is our application for program enrollment. Clicking on these links will open a secure site in a new window, allowing you to complete the forms online.
You DO NOT have to download an app.
The patient application form will auto-fill your information as you enter it, so you will not have to keep re-entering the same information.
The last four (4) pages are forms that may not pertain to your case and do not need to be filled out.
Formularios en Español
Las solicitudes son elegibles por un (1) año a partir de la fecha de aprobación.
A continuación se muestra nuestra solicitud de inscripción en el programa. Al hacer clic en estos enlaces, se abrirá un sitio seguro en una nueva ventana, lo que le permitirá completar los formularios en línea.
NO tienes que descargar una aplicación.
El formulario de solicitud del paciente completará automáticamente su información a medida que lo ingrese, por lo que no tendrá que volver a ingresar la misma información.
Las últimas cuatro (4) páginas son formularios que pueden no pertenecer a su caso y no es necesario completarlos.