Get Personal Data Card

Filling out the Personal Data Card online is an important step to access necessary support services. This guide provides comprehensive instructions on how to complete each section of the form accurately.

Follow the steps to complete your Personal Data Card online.

1. Click the ‘Get Form’ button to obtain the form and open it in your digital editor.
2. Begin by identifying whether you are a new applicant or an existing customer. Mark the appropriate option in Section 1.
3. Fill in your name and birthdate in the relevant fields provided.
4. Complete the application information with your address, city, state, zip code, home phone number, cell phone number, and email address. Indicate the best times to contact you.
5. Specify your primary language and describe your primary disability or most limiting condition in the given space.
6. Indicate whether you use any mobility aids or specialized equipment. If yes, check all that apply from the provided list.
7. Next, indicate if you require future written information in an accessible format and select your preferred format if applicable.
8. Provide information about your emergency contact, including their name, relationship to you, phone numbers, and address.
9. In Section 2, read the authorization for the release of protected health information, ensuring you understand who will have access to your information.
10. Complete Section 3 by providing the contact information for your physician or licensed professional who can verify your disability.
11. Sign and date where indicated to confirm your understanding and consent regarding the information provided.
12. If someone assisted you in completing the application, they must also provide their information and signature in Section 4.
13. Finally, review all completed sections of the form for accuracy, then save your changes, and choose to download, print, or share the form as needed.

Complete your Personal Data Card online today to access essential services.