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

  • 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 go to the "Intake Form". Complete this form and email it to:


Required Documents

  • 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

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 **