Existing Mariam Clinic Patients
Each year all existing Mariam Clinic patients are required to go through a re-qualification process. To re-qualify please read the eligibility requirements below and submit the required documents outlined in the "Required Documents" section below along with the Intake Form.
Must not qualify for public or private insurance (i.e. Medicaid, Medicare, NC Health Choice, Disablity or Veterans’ Benefits).
Permanent Resident of Wake County.
Household income no more than 200% of the poverty level (to view poverty level, click here).
If you meet the eligibility requirements click below to download the "Intake Form". Complete this form and email it to
W2 and 3 most recent pay stubs for the current year for all working members of the household.
After May 1st Tax Form 1040 (pg1 & pg 2 only) for all working members of the household. If self-employed please provide Schedule C.
If someone is supporting you, Mariam Clinic will provide you with a Letter of Support form
Complete the Intake Form & EMAIL the WORD version to
Mail the required documents to
4441-106 Six Forks Road #388
Raleigh, NC 27609
You can also email them to:
**please note that they must be in pdf format; emailed JPEGS can not be accepted **