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 (2022 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 $2,265 per month |
| 2 people | income up to $3,052 per month |
| 3 people | income up to $3,838 per month |
| 4 people | income up to $4,652 per month |
| 5 people | income up to $5,412 per month |
| 6 people | income up to $6,198 per month |
| 7 people | income up to $6,985 per month |
| 8 people | income up to $7,772 per month |
Patient Forms
Below are our patient forms. Clicking on these links will open a secure site in a new window which will allow you to complete the forms online.
The patient application forms will auto-fill your information as you enter it. You will not have to keep re-entering the same information. Please disregard the statement that says there are 216 parts to sign. Some forms may not pertain to your case and do not need to be filled out.
Los formularios de solicitud del paciente completarán automáticamente su información a medida que la ingrese. No tendrá que volver a ingresar la misma información. Haga caso omiso de la declaración que dice que hay 216 partes para firmar. Es posible que algunos formularios no correspondan a su caso y no es necesario completarlos.
Form Instructions
When you are asked to sign the form, please choose the option below. DO NOT allow the system to generate a signature. We will not be able to process your application unless it has a real signature.
Cuando se le solicite que firme el formulario, elija la opción a continuación. NO permita que el sistema genere una firma. No podremo s procesar su solicitud a menos que tenga una firma real.
