Memorial Primary Care Centers Application and Eligibility Guidelines

Here are step-by-step instructions to apply for – or renew – a Primary Care Centers Identification Card, followed by a list of documents required to determine eligibility.

New Primary Care Card Applications:

Choose one of the following options to submit your completed Financial Evaluation Form (linked below), and copies of all of the requested documents:

  • Mail to: Memorial Eligibility Department, Attn: Internet Primary Care Centers Applications, 2900 Corporate Way, Miramar, FL 33025
  • Fax to: (954) 602-2800, Attn: Internet Primary Care Centers Applications
  • Drop off copies of your documents at Memorial Primary Care Center – Hollywood, 4105 Pembroke Road, Hollywood, Florida
  • If you prefer to apply for a Primary Care Card in person, go to Memorial Primary Care Center – Hollywood, 4105 Pembroke Road, Hollywood, Florida

    • A photo ID is required to make an eligibility appointment
    • First-time applicants will have to go to the center twice – first to schedule their eligibility appointment and again on the day of the appointment
    • Call (954) 985-1551 for current hours

Primary Care Card Renewals:

You can renew your Primary Care 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 Eligibility Department, Attn: Primary Care Card Renewal, 2900 Corporate Way, Miramar, FL 33025
  • Fax to: (954) 602-2800, Attn: Primary Care Card Renewal
  • Drop off copies of your documents at the Memorial Primary Care Center – Hollywood, 4105 Pembroke Road, Hollywood, Florida
  • If you prefer to renew in person, call (954) 985-1551, ext. 2000, for an eligibility appointment

Required Documents

Below is a list of required documents that must be presented to complete eligibility. A Primary Care Centers Identification Card cannot be issued until eligibility is established.

Proof of Address:

You must have been living in South Broward Hospital District for the past three (3) months to apply for Primary Care services. Please provide bills for the last three (3) months from a utility provider (e.g., electricity, gas, telephone, water, cable or satellite television) showing your name and address. Other acceptable proofs of address include a voter registration card, or a lease agreement.

If the utility bills are not in your name, you must also bring all of the following documentation:

  • A notarized letter from the person whose name is on the bill, along with the current utility bill stating that you live at the address
  • Florida ID with current address
  • Mail or correspondence in your name received more than three (3) months prior to the appointment date

Proof of Income:

  • If married, spouse’s income is required. Please provide consecutive and complete paycheck stubs for your last six weeks of employment. If you are an unmarried parent, you must also provide the last six weeks of paycheck stubs for your children’s other parent. If you cannot provide pay stubs, you must obtain a dated letter from your employer, on company letterhead, stating hours worked and your gross pay. If you are not legally divorced, you must provide your spouse’s income.
  • Unearned income includes Aid to Families with Dependent Children, alimony, child support, disability income, Social Security income, unemployment compensation, and pensions.
  • If you do not have documented income and are being supported by another person, you must provide a notarized Letter of Support from the person who is helping you and a copy of that person’s photo ID. The letter cannot be older than 30 days, and must state how long the person has been supporting you.

Current Income Tax Return:

You must bring all pages of your most recent tax return, including W-2 forms, 1099s and all schedules. If married and filing separately, you must present both tax returns. If you do not have a copy of your tax return, you may call (800) 829-1040 to request a copy.

Bank Statements:

Please provide the last three consecutive bank statements for all of your bank accounts, including those for which you are a joint owner (checking, savings, certificates of deposit, money market accounts, etc.) Important: Online statements are not acceptable. You must provide a validated printout from the bank.

  • If you do not have a checking or savings account, please bring proof of how your bills are paid – examples include copies of money orders, cash receipts, cancelled checks for the last 3 months

Picture Identification Card:

Florida driver’s license, Florida state ID, valid passport, resident alien card, employee picture ID. The address on your identification must be current if you do not have a utility bill in your name.

Social Security Card:

A Social Security card must be presented for each member of the household. If your Social Security card has been lost or stolen, you must provide proof that you applied for a duplicate copy.

Here are documents you can use if you don’t have a Social Security card:

  • Employment authorization card or Green Card
  • Passport and I-94 card

Medicare:

If you have Medicare, or will be eligible for Medicare, please bring the card or the information stating when you will be eligible.

Medicaid:

If you have applied for Medicaid already, you must provide proof of the application. (Yellow HRS 2066 form). If you have not applied for Medicaid prior to coming to the Primary Care Center, please bring all names, dates of birth, and Social Security numbers for everyone living in your household.

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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