Get Arch Foundation Application - Therxconnect

Filling out the Arch Foundation Application - Therxconnect online is a straightforward process that requires attention to detail. This guide will help you navigate each section of the application to ensure a complete and accurate submission.

Follow the steps to complete your application smoothly.

1. Click ‘Get Form’ button to obtain the application and open it in your preferred document editor.
2. Begin with the provider information section. Fill in the provider name, facility name, facility NPI, address, city, state, zip code, phone number, fax number, contact person, state license number, and email address. If the shipping address differs, provide that information as well.
3. Indicate the clinical setting by checking all applicable boxes, including Title X, Planned Parenthood, and others as listed in the application.
4. Proceed to the provider declaration and authorization section. Read through the verification statements, ensuring all information is complete and accurate before signing and dating.
5. Next, provide patient information, including the patient's name, date of birth, address, city, state, zip code, day phone number, and evening phone number.
6. In the coverage and insurance section, answer whether the patient has Medicaid or any other form of insurance by selecting the appropriate options. If the answer is yes, explain why coverage for ® is not accessible.
7. Fill in the financial information section, providing both the current annual household income and the number of household members dependent on that income.
8. Complete the applicant declaration and authorization. Ensure that the applicant verifies all information as accurate and checks the appropriate boxes regarding consent. The patient should sign and date this section.
9. Review the entire application for completeness and clarity. Make any necessary edits before finalizing.
10. Once you are satisfied with the application, you can save changes, download, print, or share the completed form as necessary.

Complete your Arch Foundation Application - Therxconnect online with confidence today!