New Patient Forms

The Good Samaritan Clinic has several free clinic guidelines that apply to all new patients. Free clinic patients cannot have insurance (other than Medicaid) and must fall 200% or below the Federal proverty level. GSC provides care to Medicaid patients through their contract with Mountaintop Healthcare. Patients who are newly enrolled in the NC Medicaid program must have their DSS caseworker assign them to Mountaintop Healthcare for Carolina Access.

All new patients must go through an intake process. This process is also used to inform patients of our services and to establish their care. Intakes are only performed in the Waynesville location but patients may request their primary care through the Waynesville or Canton office.

GSC requires that all patients complete an intake process to verify eligibility prior to their first appointment. Patients who are uninsured and think their financial status will qualify should contact the office to schedule an intake appointment. During this phone call patients may request an intake form and a new patient form to be mailed or may download the forms below.

Patients who are newly enrolled with the NC Medicaid program and do not have a current Carolina Access provider must bring their most recent Medicaid card to the Waynesville office. A copy of the Medicaid card will be made and the first appointment will be scheduled. New patients may request paperwork to be mailed to them or this form my be downloaded below.