Eligibility Ap

Please complete this form.

Eligibility Application for Medical Services

Name:

Daytime Phone # or where message can be left:

Home Phone ( with area code):

Work Phone (with area code):

Cell Phone (with area code):

Other Phone (with area code):

Address:

City:

State:

Zip Code:

Date of Birth:

Have you been seen here before?:

Yes
No

How can we help you at this time?:

Medical
Dental

Specific problem/symptom?:

Do you have medical health insurance?:

Yes
No

Do you have dental health insurance?:

Yes
No

Have you applied for Medicaid/Medical Access Card?:

Yes
No

If denied, Reason for denial?:

How many people are in your household?:

What is your gross income (before taxes)?:

Weekly?:

Monthly?:

Yearly?:

Other (Specify Details)?: