To become eligible for services, please complete the following form:
Patient Application Form

Once completed, you may mail it to:

Hannibal Free Clinic
160 Progress Road
Hannibal, MO 63401

Click here to send application by email.

Or fax it to 573-248- 8350
Attention: Clinical Coordinator.

Or hand-deliver it to the Hannibal Free Clinic.
Attention: Clinical Coordinator.

We will review your application and contact you regarding your eligibility to be cared for at the Hannibal Free Clinic. Please be sure to complete your application completely and attach supporting income verification.  Applications cannot be considered without this information.  Failure to provide all requested information will slow the application process and delay your appointment.