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South Broward Community Health Services Application and Eligibility Guidelines

Here are step-by-step instructions to apply for – or renew – a South Broward Community Health Services Identification Card, followed by a list of documents required to determine eligibility.

New South Broward Community Health Services Card Applications

Choose one of the following options to submit your completed Financial Evaluation Form and copies of all the requested documents:

  • Mail to: Memorial Healthcare System, PO Box 863436, Orlando, FL 32886-3436, Attn: South Broward Community Health Services Eligibility
  • Fax to: (954) 602-2800, Attn: South Broward Community Health Services Applications
  • Drop off copies of your documents in one of the "drop boxes" located at:
    • South Broward Community Health Services, 4105 Pembroke Road, Hollywood, Florida
    • South Broward Community Health Services, 1750 East Hallandale Beach Boulevard, Hallandale Beach, Florida

If you are approved, you will receive your South Broward Community Health Services Card in the mail. You will also be notified by mail if your application is denied, or if there are questions.

If you prefer to submit your documents in person, please go to South Broward Community Health Services at 4105 Pembroke Road in Hollywood, Florida 33021. Call 954-265-8459 for hours of operation.

A copy of your photo ID must be submitted with your documents.

South Broward Community Health Services Card Renewals

You can renew your South Broward Community Health Services Card by submitting a completed Financial Evaluation Form (linked below), along with copies of all of the requested documents, by one of these methods:

  • Mail to: Memorial Healthcare System, PO Box 863436, Orlando, FL 32886-3436, Attn: South Broward Community Health Services Eligibility
  • Fax to: (954) 602-2800, Attn: South Broward Community Health Services Card Renewal
  • Drop off copies of your documents in one of the "drop boxes" located at:
    • South Broward Community Health Services, 4105 Pembroke Road, Hollywood, Florida
    • South Broward Community Health Services, 1750 East Hallandale Beach, Boulevard, Hallandale Beach, Florida

If you are approved, your South Broward Community Health Services Card will arrive by mail. You will also be notified by mail if your application is denied, or if there are questions.

Or, you may submit your documents in person by either:

  • Calling 954-265-8459 for an appointment, or
  • Stopping by South Broward Community Health Services at 4105 Pembroke Road in Hollywood, Florida 33021; call 954-265-8459 for hours of operation

A copy of your photo ID must be submitted with your documents.


You MUST be uninsured, not eligible for any other government medical program, and live in the South Broward Hospital District to be eligible for services with the South Broward Community Health Services Program of Memorial Hospital.

Documents Required

Copies of the following documents must be presented to determine eligibility. A South Broward Community Health Services Identification Card cannot be issued until eligibility is established.

Proof of Medicaid/Medicare Application: 

  • Must provide a Department of Children and Families access number (see Medicaid section below)
  • All applicants 65 years or older or disabled must apply for Medicare in addition to applying for Medicaid

Identification

  • All patients must provide a current Florida ID or Driver’s License showing your current address AND your Social Security Card with ONE of the following for each member of the household:
    • US passport
    • Voter registration card
    • U.S. Birth Certificate
    • Permanent Resident card
    • Work Authorization card
  • If you do not have a Florida ID or Social Security card, you must provide your Passport with Visa and I-94

Proof of Address (please provide one of the following):

  • Current utility bill (e.g., electricity, telephone, gas, water or cable)
    • f you DO NOT have a utility bill in your name, provide ONE of the following documents:
      • A notarized letter from the landlord or home owner stating that you live at that address WITH a current utility bill in their name
      • A current Lease Agreement

Proof of Income – if legally married or unmarried partners with children, income for both MUST be provided:

  • Paycheck stubs showing your gross income for the last 6 weeks for you and your spouse or Domestic Partner
    • If you are unable to provide paycheck stubs, provide ONE of the following documents:
      • A dated letter from your employer, on company letterhead, stating hours worked and gross pay
      • Completed Declaration of Income form
  • All unearned income must be provided
    • If you are being supported by another person, provide a notarized Letter of Support from the person who is helping you with a copy of the supporter’s photo I.D. (Letter CANNOT be older than 30 days)
    • AFDC, Alimony, Child Support, Disability Income, Social Security Income, Unemployment Compensation, Pensions, Dividend income, Annuities, Worker’s Comp, etc.

Bank Statements

  • Last 3 consecutive statements for ALL personal (checking, savings, IRAs, CDs, money market, and bonds) AND business bank accounts for you, your spouse (or Domestic Partner), and dependents
    • If you do not have a bank account you must provide proof of payment for all monthly expenses for the last 3 months (e.i: money orders, cash receipts, cancelled checks)

Current Income Tax Return – if filing separate, both Tax Returns must be provided

  • Personal and Business income tax returns for you and your spouse or Domestic Partner
    All pages must be provided including 1040 forms, W-2 forms, 1099’s and all schedules

Please allow 90 days for processing and review.

Medicare:

If you have Medicare, or will be eligible for Medicare, please submit a copy of your card or of the document stating when you will be eligible.

Medicaid:

If you have applied for Medicaid already, you must include a copy of your application in the documents you submit to the South Broward Community Health Services (Medicaid access number or Medicaid approval or denial letter).

South Broward Community Health Services Eligibility Medicaid Screening:

Please answer the following questions if you are applying for South Broward Community Health Services services.

  • 1. Are you a United States citizen or a legal resident for five years or longer?
  • 2. Are you 65 or older, or receiving disability benefits?
  • 3. Do you have any dependent or adopted children under 18 years old?

If you answered yes to Question 1 and Question 2 or 3, you must apply for Medicaid prior to your scheduled eligibility appointment.

You must provide proof you have applied for Medicaid (access number), along with all of the required documents (see above).

(Please go to http://www.myflorida.com/accessflorida/ and click on "Apply for Benefits" to complete a Medicaid application.)

Proof of Legal Guardianship (if applicable):

If you are a legal guardian, you must provide us with the proper custody or legal documents.

Additional Information and or documentation may be requested to complete your application. All information is subject to verification. Providing false information may result in the denial of any type of financial assistance through the South Broward Hospital District d.b.a. Memorial Healthcare System.

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