What are the requirements to receive services at 5:16 Clinic?
- Applicants must be residents of Pulaski County.
- Applicants must provide proof of residency (cable or utility bill, or a copy of a current lease from your landlord).
- Applicants must provide valid identification (driver’s license or other picture ID).
- Applicants must complete, sign and submit all necessary paperwork.
- Applicants must be actively employed, with a total household income no more than 200% of the Federal Poverty Rate. (Please see chart below.)
Qualifying Income Thresholds by Family Size
| Size of Family | Maximum Annual Income |
|---|---|
| One Person | $29,160 |
| Two People | $39,440 |
| Three People | $49,720 |
| Four People | $60,000 |
| Five People | $70,280 |
| Six People | $80,560 |
| Seven People | $90,840 |
| Eight People | $101,120 |
| Nine People or More | $111,400 |
Please note: Medicaid recipients are NOT eligible, because they have existing coverage. Medicare recipients are not eligible for medical services, but may be eligible for dental services, if they are actively employed.
Please mail your completed forms, along with the required support documents to: 5:16 Clinic, 810 E. Mt. Vernon St., Somerset, KY 42501.
(If you don’t have access to a printer, email: contact@516clinic.org and request that we mail you copies of the forms.)
Applications received will be submitted to the 5:16 Clinic screening committee for verification and review. We will notify you if you qualify – or if you don’t – by phone, email or U.S. mail.
If approved, we will also contact you to set up an appointment. You will be issued a certification card which will be good for six months, unless your circumstances change prior to that. At the end of six months, you will need to submit updated information if you wish to continue receiving care.
** 5:16 Clinic is not able to provide acute or emergency care. All patients must go through the approval process before being treated. Services are provided by appointment only. **
*Patient Non-Discrimination Policy: The 5:16 Clinic is committed to providing quality service to patients of all backgrounds. In accordance with this mission, the 5:16 Clinic does not exclude, deny service to, or otherwise discriminate against any person on the basis of age, sex, marital status, creed, race, color, national origin, or any other legally protected class or on the basis of disability or age in admission to, participation in or receipt of any of its services. *This statement is in accordance with the provisions of Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, The Age Discrimination Act of 1975, and Regulations of the U.S. Department of Health and Human Regulations Part 80, 84, and 91.