Eligibility For Free Care
The Albrecht Free Clinic is proud to offer free medical and dental care to qualifying individuals. To qualify for services, individuals must:
- Live or work in Washington County
- Have no insurance coverage
- Have a household income at or below 200% of the Federal Poverty guidelines
If you meet the above requirements, we encourage you to apply. Here’s how:
- Print and complete the following form:
Patient Application - English | Patient Application - Spanish/Español
- Provide proof of address* or employment in Washington County. The following are acceptable documents:
- Current WI Drivers license or WI ID card with current address
- Utility statement with current address
- Rental agreement
- Paycheck stub with employers name and address
*If you are currently without a home, you may still apply if you provide a signed letter from the person currently providing you shelter, along with proof of their address.
This can be a family member, friend, or shelter facility.
- Provide income documentation. The following are acceptable documents:
- Paycheck stubs showing one month’s worth of consecutive income for each working individual in the household
- Social Security letter stating monthly benefits
- Dental patients should complete a Medical/Dental History Form (Historical Médico/Dental - Español) and submit with the application.
*Please keep in mind that communications via email are not secure. Although unlikely, there is a possibility that information you include in an email can be intercepted and read by other parties besides the person to whom it is addressed. If submitting a Medical/Dental History Form, we prefer that you drop it off at our office.
- Once application is complete and you have copies of your proof documents, you can mail to or drop off at 908 W. Washington St., West Bend, WI, 53095, fax it to (262) 306-7717, or email it to email@example.com.
- Our team will review your application and documents, and contact you to schedule an appointment. We may schedule a same-day appointment if available.