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APPLICATION FOR SERVICES
Name _______________________________________________
Address______________________________________________ _______________________________________________
Phone Number _________________________________________
Date of Birth ___________
Social Security # _____________________ Female Male
Married Single Divorced Widowed
Ethnicity Caucasian African-American Hispanic Other
INSURANCE:
Medicaid#______________________(If rejected we need copy of Medicaid letter)
Medicare#_________________________ VA ____________________
Other Insurance___________________________________________
(Name and policy number )
Notes: _________________________________________________________________________
____________________________________________
Primary Care Doctor ____________________________________________
Other Doctors: ________________________________________________
FINANCES (Fill in all monthly income and assets) (indicate pay period-wk, month)
Patient Spouse/other
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Salary/Wages from: |
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Social Security |
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SSI (Supplemental Security Income) |
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Pension/Retirement from: |
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Unemployment Compensation |
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Workers Compensation |
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Alimony/child support |
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TOTAL |
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TOTAL GROSS INCOME FOR HOUSEHOLD $ ________________
Assets Patient
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Checking Acct |
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Savings Account |
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CD’s |
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IRA/retirement/annuity |
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Other |
MEDICATIONS:
LIST ALL MEDICATIONS ( prescrtion over-the-counter, herbals, vitamins, etc. that you take)
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Name of Medicine |
Strength |
How often taken? |
Prescribing Doctor |
ALLERGIES to medicines ( list each allergy and the reaction you had to that medicine)
- _________________________________________________________
- _________________________________________________________
- _________________________________________________________
- _________________________________________________________
********* I certify that I have NO health insurance including Medicaid, Medicare and VA. I also state that the information I have provided is true and complete to the best of my knowledge. I have read the information above and agree with it. I hereby give CCCP permission to verify this information.
Signed _________________________________ Date ____________________
Initials: ______ I hearby give my permission to share the above information with any agency that may help me in receiving prescription assistance.
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# in household _______ 200% of poverty _____________
ELIGIBLE _______ NOT ELIGIBLE ___ (if not eligible, indicate reason ) ________________________________________________________________________________________________________________________________________________________________________________________________
Signed ________________________________date________________
Pharmacy Intake Personnel