Get Akdc Application Form.doc. Akdc Referral Application - Ace Arkansas

Filling out the AKDC Application Form is an essential step for anyone seeking services from the Arkansas Kidney Disease Commission. This guide will provide you with clear and concise instructions to complete the form accurately and efficiently.

Follow the steps to fill out the AKDC Application Form.

1. Press the ‘Get Form’ button to access the AKDC Application Form, allowing you to view and fill it out online.
2. Begin with the date field at the top of the form. Enter the date on which you are completing the application.
3. Next, fill in your name in the designated field. Ensure that the name matches your identification documents.
4. Provide your Social Security number in the corresponding field. This information is crucial for identifying your application.
5. Enter your date of birth in the appropriate field to confirm your identity.
6. Indicate your race. This information may be used for demographic purposes by the commission.
7. Select your sex by marking the appropriate box for either male or female.
8. Fill in your complete address, including city, state, zip code, and county, to ensure proper contact and service.
9. Provide your primary phone number in the designated field, along with an optional alternate phone number, if applicable.
10. If there is a contact person or message, include their name and phone number in the designated section.
11. Indicate whether you have applied for Medicare and Medicaid by selecting 'Yes' or 'No' for each, and provide the relevant numbers if applicable.
12. Mention if you have private health insurance and if it includes medication coverage.
13. State whether you have Veteran’s Health Benefits and if it includes medication coverage.
14. Provide details about your renal social worker, their unit, and contact information, if assigned.
15. Indicate if you should be referred for Vocational Rehabilitation Services with a yes or no answer.
16. Fill in the date of your first dialysis and whether it occurs in a center or at home.
17. If applicable, enter the date of your transplant and the contact information for the medical facility.
18. Provide information regarding other medical conditions that may be relevant.
19. Read the section on confidentiality carefully and ensure you understand the implications of sharing your personal information.
20. Finally, sign the form where indicated, with the date, to certify that the information provided is accurate.

Complete the AKDC Application Form online today to begin receiving the support you need.