How to Become a Patient
Qualification Procedure
To become qualified as a patient you must make an appointment to determine eligibility. For your convenience you may download the registration forms below and fill them out in advance. In addition to the forms here, the following documents must be presented at the first appointment:
Patients will be requalified in May of each year by providing a copy of their current income tax return or other current proof of income. These items may be faxed to New Patient Services, 251-460-0992.
Current local photo identification
Social Security Card
Proof of Residence, such as utility bill, lease agreement, etc.
Proof of all household income*
*Current tax return for the household (required if filed) OR Four current pay stubs for each employed person in the household OR A notarized letter of employment for each employed member of the household stating the average number of hours worked per week and the gross rate of pay.
Patient Fees
Patient fees are calculated on a sliding scale that is based on family size, gross family income and circumstances. Patients who have not yet qualified will pay $60 per office visit for up to two physician visits. Non-qualified patients are also eligible for one lab visit ordered by Victory physicians. The cost of the lab visit depends on the type and number ordered.
Victory does not bill patients for services rendered. Patients are expected to pay for services at the time of the office visits with cash or check.
Lab fees are a separate charge and are also due at the time of service. Through a donation from Quest Labs we are able to keep our lab fees low.
To be a patient of the clinic, a $60 annual administrative fee is required. This fee enables Victory to provide additional services to our patients without charging extra fees for those services. Examples of additional services are Patient Assistance Program (PAP), Medication Dispensary, Urine Tests, Strep Tests, X-Rays, EKG’s and Counseling.
Thank you for helping Victory qualify you as a patient.