Eligible applicants must:
- Be at or below 200% of the Federal Poverty Level or below (for Sliding Fee Discount Schedule ONLY)
- Fully complete a new patient application (click the appropriate button below to download an application)
In addition to a completed patient application, one copy of each of the following documents are also required.
Only completed applications with copies of the required documents will be processed.
- Copy of Social Security card (if available) for each applicant
- Copy of picture identification for each applicant
- Family proof of earned income, if applicable:
- Current Federal income tax return
- Social Security or disability letter (must be a letter from Social Security Administration)
- 30 days paystubs (most recent)
- Unemployment Benefits (must be a letter from Unemployment department)
- Letter from a shelter on organizational letterhead where applicant resides
- Letter from employer on company letterhead documenting the hours worked and rate of pay or signed and notarized GSCC Employer Declaration Notice
- Department of Human Services Child Support Statement or proof of alimony
- Self-declaration on GSCC Self-Declaration Form is allowed for homeless individuals/families
ALL paperwork must be completed prior to being seen at the clinic.
English Applications and Forms:
Aplicaciones y formas en Español:
Good Shepherd community clinic, Inc.
Twenty 12th Avenue NW
Ardmore, Oklahoma 73401
Monday 9a to 6p
Tuesday 9a to 6p
Wednesday 9a to 6p
Thursday 9a to 6p
Friday 8a to 12p