Patient Eligibility Form
The clinic is NOT a walk-in clinic and requires prior qualification before any appointments.
Patients with ANY INSURANCE are not eligible.
To begin the qualification process, please stop by the corporate office to pick up an application form or follow the steps below:
1) Download the 1 page application form below.
2) Completely fill and sign the application form. If something does not apply to you, simply mark N/A or indicate that this does not apply to you.
3) Once completed, mail OR drop off your completed applications to the following address:
light ones path foundation INC.
Attn: Eligibility Coordinator
601 E Sample Road , Suite #101
Pompano Beach, FL 33064
NOTE: Please keep in mind that incomplete application will delay the approval and processing of your application.
Once we have received your completed application, it takes approximately 5-7 days for a response.
Please take a look on the federal poverty level chart below to validate the eligibility criteria
1) Download the 1 page application form below.
2) Completely fill and sign the application form. If something does not apply to you, simply mark N/A or indicate that this does not apply to you.
3) Once completed, mail OR drop off your completed applications to the following address:
light ones path foundation INC.
Attn: Eligibility Coordinator
601 E Sample Road , Suite #101
Pompano Beach, FL 33064
NOTE: Please keep in mind that incomplete application will delay the approval and processing of your application.
Once we have received your completed application, it takes approximately 5-7 days for a response.
Please take a look on the federal poverty level chart below to validate the eligibility criteria
| eligibility_form.pdf |
