 Resident of Burke County
 Uninsured (including private health insurance, Medicaid, Medicare, or receive Veteran’s benefits and if requesting dental care – dental insurance)
 Between the ages of 18-64
 Household Income less than 200% Federal Poverty Level

2018 Income Guidelines

200% of the Federal Poverty Level

Income eligibility for the Burke Health Network is based on household size and financial thresholds listed below.

HOUSEHOLD/ FAMILY SIZE

MONTHLY    ANNUAL
1 $2,023         $24,280
2 $2,743         $32,920
3 $3,463         $41,560
4 $4,183          $50,200
5 $4,903         $58,840
6 $5,623         $67,480
7 $6,343         $76,120
8 $7,063        $84,760

For families with households with more than 8 people, add $4,160.00 annually for each additional person.

Eligibility Supporting Documents: Identification, Residency and Insurance Status

 Photo ID
 Current Burke County Address Verification
 Medicaid Denial Letter
 Statement from Head of Household or Person Supporting You

Financial Statements
 Proof of gross monthly income for the past 30 days for you and members of your household if currently working
 Previous year’s Federal Tax return 1040 (if you filed) or 4506-T signed and dated
 Bank Statement
 Social Security Rulings or Supplemental Security Income (SSR or SSI) for you and members of your household
 Social Security Disability Income Statements with Medicare status for you and member of your household
 If applying for any of the above, Current Status Statement required

Other Statements that may apply
 Retirement, Pension, Unemployment Benefits, Insurance letter
 Child Support, Alimony, Pell Grant Refund, VA benefits
 Medication or List of Medication

For enrollment or eligibility related questions or to schedule an appointment, please call:

One North Square
(828) 334-6159
Good Samaritan Clinic
(828) 212-4169

Business Hours
Monday – Friday
8:00 AM – 5:00 PM