Becoming a New Medical Patient
How It Works:
We offer scheduled sign-up days and separate registration days for new patients:
On the Sign-Up Date, you will fill out the New Patient Interest Form online.
After you sign up, our team will call you to confirm your Registration Date, which is the day you will come to the clinic in person to complete your registration.
Please note: You must wait for a confirmation call before arriving at the clinic. Online sign-up spots are limited and filled on a first-come, first-served basis. The online sign-up form closes once every slot is full.
Medical Registration for 2025:
January 17 - CLOSED
February 14 - CLOSED
March 14 - CLOSED
April 11 - CLOSED
May 9 - CLOSED
July 11: Sign-up Opens June 13 at 8:30 AM (ONLINE ONLY) - CLOSED
*FUTURE DATES TO BE DETERMINED
Please note: This is not a medical appointment — you will not see a doctor on this day. This visit is only for completing the registration process.
After completing your registration appointment, you'll be eligible to schedule your first medical visit and may be referred for additional services, if needed.
Becoming a New Dental Patient
How It Works:
We offer scheduled sign-up days and separate registration days for new patients:
On the Sign-Up Date, you will fill out the New Patient Interest Form online.
After you sign up, our team will call you to confirm your Registration Date, which is the day you will come to the clinic in person to complete your registration.
Please note: You must wait for a confirmation call before arriving at the clinic. Online sign-up spots are limited and filled on a first-come, first-served basis. The online sign-up form closes once every slot is full.
Dental Registration for 2025:
January 22 - CLOSED
February 19 - CLOSED
March 19 - CLOSED
April 16 - CLOSED
May 14 - CLOSED
June 18 - CLOSED
July 16: Sign-up Opens June 18 at 8:30 AM (ONLINE ONLY)
September 17: Sign-up opens on August 20 at 8:30 AM (ONLINE ONLY)
*FUTURE DATES TO BE DETERMINED
Please note: This is not a dental appointment — you will not see a dentist on this day. This visit is only for completing the registration process.
After completing your registration appointment, you'll be eligible to schedule your first dental visit and may be referred for additional services, if needed.
IMPORTANT NOTICE
To complete your registration, you MUST bring physical (paper) copies of your proof of income to your scheduled registration appointment.
- Electronic versions (on phones, emails, or other devices) will NOT be accepted.
- We are unable to print documents for you at the clinic.
If you do not bring printed proof of income, your registration will be rescheduled for the next available date next month.
Keep reading below to learn what documents and requirements you’ll need for registration.
New Patient Requirements
To schedule your first appointment, please prepare the following:
1. Valid Photo ID
Bring a current, government-issued photo ID (e.g., driver’s license or passport)
2. Deposit Payment
A $45 deposit is required at the time of registration. We accept cash and debit/credit cards, check.
- This deposit will be applied toward your total charges on your first visit.
- Final charges will vary based on the services received and federal poverty guidelines.
Have Medical Insurance?
If you provide a valid insurance card at registration, the $45 deposit is waived. Instead, you’ll be charged the co-payment amount required by your insurance.
Please note: We only accept medical insurance. Dental services are not covered by insurance at our center and must be paid out of pocket.
Accepted Medical Insurance Plans:
- Medicare
- Medicaid
- Oscar
- Ambetter
- Aetna
- Humana
- Medicare Advantage Plans
- United Health Care
- Blue Cross Shield
3. Proof of Household Income
Good Samaritan Health Center of Cobb defines a household as anyone who is financially dependent on or supporting one another.
Please note: We are not a free clinic — fees are based on a sliding scale depending on your income and household size.
You must provide two forms of income verification. See options below:
Option 1 - Getting Paid by Check
- Most recent federal income tax return (full packet, including all forms and schedules)
- Three months of most recent pay stubs (consecutive, no gaps) for all working members of the household
For example:
• If paid weekly, provide your last 12 pay stubs
• If paid bi-weekly, provide your last 6 pay stubs
Option 2 - Getting Paid in Cash
- Notarized letter from employer(s) or letterhead from the employer providing an estimate of your salary and how often
- Three most recent bank statements (including all pages) showing any of the following:
- Checking/savings/investment account balances
- Department of Labor deposits
Option 3 - Homeless
- You must provide a shelter letter. A shelter letter is required at each appointment and must be dated the same date as the appointment
Option 4 - Other
- Three most recent bank statements (including all pages) showing any of the following:
- Checking/savings/investment account balances
- Department of Labor deposits
- Most recent federal income tax return (full packet, including all forms and schedules)
Any financial assistance
For example: Food stamps, SSI, Disability.
Option 4- Dependents
- Provide a notarized letter from the financial provider (Good Samaritan defines a financial provider as someone who offers you shelter, food, transportation, insurance, and/or monetary value of the assistance provided)
Please note: This letter is only required if the dependent is not listed on the tax form.
