Existing Mariam Clinic Patients
Annual Requalification
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.
Eligibility Requirements
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Must not qualify for public or private insurance (i.e. Medicaid, Medicare, NC Health Choice, Disablity or Veterans’ Benefits).
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Permanent Resident of Wake County.
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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 go to the "Intake Form". Complete this form and email it to:
Required Documents
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W2 and 3 most recent pay stubs for the current year for all working members of the household.
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After May 1st Tax Form 1040 (pg1 & pg 2 only) for all working members of the household. If self-employed please provide Schedule C.
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If someone is supporting you, Mariam Clinic will provide you with a Letter of Support form
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Complete the Intake Form & EMAIL it to director@mariamclinic.org
Mail the required documents to
Mariam Clinic
4441-106 Six Forks Road #388
Raleigh, NC 27609
You can also email them to: director@mariamclinic.org
**please note that they must be in pdf format; emailed JPEGS can not be accepted **