Follow the steps to successfully complete the form.

1. Click the ‘Get Form’ button to retrieve the form and open it in your editor.
2. Begin by entering the date at the top of the form. Ensure that you use the correct format of MM/DD/YYYY.
3. Indicate whether you are a green card holder or citizen by selecting the appropriate option.
4. Fill in your last name and first name accurately, ensuring proper spelling.
5. Select your gender by marking 'M' for male or 'F' for female, as applicable.
6. Enter your date of birth in the required format (MM/DD/YYYY) and state your age.
7. Complete your address details including street address, apartment number, city, state, zip code, and county.
8. Indicate your marital status and who you are living with, along with the language you speak.
9. Provide your annual income and specify the source of income, selecting from SSI, S.S., or other.
10. Fill out the emergency contact information, including the names, relationships, and telephone numbers for up to three contacts.
11. Enter your doctor's name and their contact number. Also, fill out the name and address of the hospital or clinic you attend.
12. Mark any relevant medical conditions or health problems from the options provided, and describe any other medical conditions in the space available.
13. Complete the sections related to referral to the case coordinating unit by indicating if referred, and provide the agency's name.
14. Once all fields are filled out, review your entries carefully for accuracy. You can then save your changes, download, print, or share the completed form as needed.

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