Get Compassionate Care Program Patient Enrollment Form

Filling out the Compassionate Care Program Patient Enrollment Form online is a crucial step in accessing fertility treatment resources. This guide provides a clear and supportive roadmap for completing each section of the form accurately and efficiently.

Follow the steps to successfully complete the Patient Enrollment Form.

1. Press the ‘Get Form’ button to obtain the enrollment form and open it for editing.
2. Begin by entering your personal information. Fill out your first name, last name, middle initial, and date of birth in the corresponding fields. Make sure all names are spelled correctly for accurate identification.
3. Indicate your gender by selecting either 'Male' or 'Female'. This helps personalize your experience within the program.
4. Provide your home phone number and mobile phone number in the designated fields. Choose your preferred method of contact, ensuring you select options for home phone, mobile phone, or email as applicable.
5. Fill in your mailing address, including city, state, and zip code. Ensure accuracy to facilitate any potential communication related to the program.
6. Indicate your military status by selecting whether you or your partner are active duty or retired US Military personnel. If applicable, specify the branch of service.
7. Indicate your dates of service by entering the start and end dates in the format provided (Month/Day/Year). This information is essential for program eligibility.
8. Answer the questions regarding your fertility treatment, including whether you are currently undergoing treatment and if you have been diagnosed as requiring assisted reproductive technologies.
9. Document the prescribed products accurately by checking the relevant options that apply to you, such as -f or .
10. Send your income verification form via fax, mail, or email using the indicated contact information. This verification is vital in establishing your eligibility for the program.
11. Include the total number of people living in your household. This helps in determining the income eligibility.
12. Read the patient signature and authorization section carefully. You must sign and date the form to certify all information is accurate and complete.
13. Finally, save your changes, download a copy for your record, or print the form for submission. Ensure you keep a copy for your records.

Start filling out the Compassionate Care Program Patient Enrollment Form online to access important fertility treatment resources.