Get Enrollment Form: Patient Application -

This guide provides clear instructions on how to complete the enrollment form for the patient application online. Filling out this form accurately is essential to ensure that you receive the assistance you need.

Follow the steps to fill out the enrollment form effectively.

1. Press the ‘Get Form’ button to obtain the enrollment form and open it in your preferred editor.
2. Begin by providing your personal information. Fill in your full name, ensuring you include both first and last names. Select your sex by checking the appropriate box, and enter your complete address along with your email.
3. Next, fill in your contact information. This includes your daytime and evening telephone numbers. Ensure you provide the correct state and ZIP code.
4. Indicate if you are a resident of the U.S., Puerto Rico, or the U.S. Virgin Islands by checking the appropriate box.
5. Moving on to the insurance information section, state whether you have insurance by checking 'Yes' or 'No'. If you answered 'Yes', provide the name of your primary insurance company and policy details. Attach a photocopy of your insurance card if necessary.
6. In the patient financial information section, indicate the total number of people in your household and provide your household's total annual income. Ensure to attach supporting documentation such as your most recent federal tax return if applicable.
7. Sign the patient declaration section affirming that the information provided is accurate. Make sure to include the date of your signature.
8. Finally, review the completed form for accuracy, and proceed to save your changes. You can download, print, or share the completed form as needed.

Take the first step towards assistance — fill out your enrollment form online today!