Get Nv Health Centers Whc Enrollment Form Fy20 2019-2025

Filling out the NV Health Centers WHC Enrollment Form FY20 online is an essential step for individuals seeking to access vital women's health services. This guide provides clear, step-by-step instructions to help users navigate the form effectively.

Follow the steps to successfully complete the enrollment form.

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out your personal information including your Social Security Number (SSN), date of birth (DOB), last name, first name, age, birth place, and middle initial.
3. Provide your contact details, including your street address, city, zip code, home phone number, work phone number, and cell phone number.
4. Indicate your ethnic background by selecting if you identify as Hispanic, and specify your race from the available options.
5. Inform whomever referred you to the program by indicating how you heard about this program.
6. Complete your occupational information, including your job title or position and the industry in which you work.
7. Fill in your education level by indicating the highest grade completed.
8. Proceed to the applicant eligibility information section. Indicate if you have medical insurance, Medicare Part B, or Medicaid. Provide details related to your insurance and household income.
9. In the applicant medical history information section, specify any breast or cervical health history and complete related questions including symptoms, previous screenings, and treatments.
10. Fill out additional general health information, such as your height, weight, and smoking status.
11. Review the informed consent and release of medical information section, then indicate whether you authorize WHC to send text message reminders.
12. Sign and date the form to confirm your consent to participate in the program.
13. Lastly, provide contact information for a friend or family member that WHC may contact if you cannot be reached.
14. Once all sections are completed, save your changes. You can download, print, or share the completed form as necessary.

Complete your enrollment form online today to access essential women's health services.