Get Open Door Health Center Patient Application Phone: (305) 2462400 Fax: 3052465010 In Order To

The Open Door Health Center patient application is a crucial document for individuals seeking medical services. Completing this application accurately is essential for approval and receiving the necessary healthcare support.

Follow the steps to fill out the form effectively.

1. Press the ‘Get Form’ button to access the application form and open it in your preferred editor.
2. Begin by filling in the contact information, including your last name, first name, and two phone numbers. Ensure the information is correct and up to date.
3. Provide your full address, including the city and ZIP code. This information determines your eligibility based on residency.
4. Fill in your Social Security number and date of birth. Select your marital status by marking 'Married' or 'Single'.
5. Indicate whether you are permanent or migrant, and fill in your sex and race.
6. Complete the birthplace section and your mother’s maiden name. If applicable, provide the name and contact information of your guardian or spouse.
7. Answer if you or your children have any form of medical insurance and if you receive food stamps or similar benefits.
8. Fill in your family yearly income, hourly income, and the size of your family.
9. List each member of your household, including their names, relationships, and birthdates.
10. Provide your occupation, education grade completed, and native language, along with place of employment and whether you can read and write.
11. Indicate the reason for your referral and provide the name of the individual or entity that referred you.
12. Complete the section requiring your acknowledgment. Certify that the provided information is accurate and sign the form.
13. Save changes, download, print, or share the completed form as necessary.

Start your application process online today to access essential health services.