New Patient/Renewal Application Form

New Patient/Renewal Application Form
For questions about your eligibility or this application form, contact frontdesk@greenecareclinic.org or call (434) 985-7000.
Is this a new application, or are you renewing your card?

NewRenewal
How did you hear about the Clinic?*

Advertisements/MarketingHealth DepartmentSocial Media (Facebook)UVA HealthSentara Martha JeffersonFaith OrganizationPersonal ReferenceClinic WebsiteOther
What services do you need help with (check all that apply)?*

MedicalDentalNon-narcotic prescriptionsVisionNutrition counselingSmoking Cessation CounselingBehavioral Health/Counseling
Do you have Medicaid or Medicare?*

YesNo
Do you have a Medicaid application pending? *

YesNo
Do you have a Medicaid Denial Letter?

YesNo
Please describe any medical issues you are currently experiencing
Name of the Patient*

First NameMiddle InitialLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary phone number to contact patient*

Area CodePhone Number
Is the primary phone number a cell phone?*

YesNo
Can the primary phone number provided receive text messages?*

YesNo
Is there a secondary phone number where we can contact you?

Area CodePhone Number
Does the secondary phone number receive text messages?

YesNo
Email
example@example.com
Current age*
Date of Birth*

MonthDayYear
Date
Last 4 digits of Social Security number*
Marital status*

SingleMarriedSeparatedDivorcedDomestic PartnershipWidowed
Gender assigned at birth*

MaleFemale
With what gender do you identify?*

MaleFemaleNon-binaryDecline to answer
Employment Status*

UnemployedFull-timeDisabledDependentPart-timeRetiredStudentSeasonal
Name of Employer(s)
Employer Phone Number

Area CodePhone Number
Is the patient of Hispanic, Latino, or Spanish origin?*

No, not of Hispanic, Latino, or Spanish originYes, Mexican, Mexican American, ChicanoYes, Puerto RicanYes, CubanYes, another Hispanic, Latino or Spanish origina such as Salvadoran, Dominican, Columbian, Guatamalan, Spaniard, Equadorian, etc.
Does the patient need a Spanish Interpreter?*

YesNo
Would you say you are:*

Native American / Alaskan NativeAsianAfrican-American / BlackPacific Islander / Native HawaiianCaucasian / WhiteHispanic / LatinoOther
Emergency contact name

First NameLast Name
Emergency contact phone number

Area CodePhone Number
Household size (Tax filer + spouse, if married + tax dependents = household size)
Names and ages of any dependents listed on your tax return*
Name of spouse (if married)
Did you file a State or Federal tax return last year? *

YesNo
Do you expect to file a State or Federal tax return this year?*

YesNo
Patient's monthly gross income*
Please enter your income before taxes, including SSI, Disability, Rent, Royalty, Pensions, Alimony, and/or Family/Friend support.
If married, spouse's monthly gross income
Please enter your income before taxes, including SSI, Disability, Rent, Royalty, Pensions, Alimony, and/or Family/Friend support.
Is there anything else you'd like to know?
Please upload the following documentation: 1) a copy of your ID (e.g., driver's license, state or school ID, voter registration card), 2) proof of residence (e.g., utility bill, bank or credit card statement) and 3) proof of income (e.g., paystub, tax return, unemployment benefit form) OR 4) a signed letter of support from a friend or family member that states that they cover your living expenses (food, shelter, etc.).

Browse Files

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Trouble uploading or attaching files? You may email them to frontdesk@greenecareclinic.org. Need more help? Please give us a call at (434) 985-7000.
I hereby grant the Greene Care Clinic permission to verify and discuss my medical and financial information with those directly involved with my care, e.g., physicians, pharmacists, and others as directly relates to my care. Any other request for medical information will require my prior authorization. I hereby grant the Greene Care Clinic permission to share my name and demographic information (i.e., age, marital status) to the Virginia Department of Social Services and other agencies that may be able to provide me with additional assistance. By typing my name and today's date in the space below, I hereby certify that the information I have provided is true and complete.
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