Income Information: Please list the amount of income, before taxes, earned by ALL PERSONS in the family unit that you listed on this form.

Include the following types of income: wages/salary/self-employment, child support/alimony, interest/dividends, disability benefits, retirement benefits, Social Security Income, Unemployment benefits, and any other type of income. Do not include income from loans.

Patient: I CERTIFY that that this information is true and accurate to the best of my knowledge. I understand that the information is subject to verification. I understand that if my financial situation changes or I obtain health insurance, my eligibility status will need to be re-evaluated. I understand it is my responsibility to notify THE CLINIC of any changes in my financial situation. I authorize the release of my financial records (including Social Security Number) to RX Partnership, pharmaceutical companies and Access Now and/or their agents to determine my eligibility for financial assistance for medicines and verification during routine audits. This review is a check on eligibility only. It is not a guarantee that I will receive benefits from any source, and THE CLINIC offers no such guarantees. I understand that falsification of information submitted will jeopardize my consideration for the program.

I certify that based upon the information provided, the individual is eligible for Access Now Services:

Please upload your proof of identification, your photo ID. It must include: 

1) Photo

2) Date of Birth

3) Legal Name 

 

It can be from a foreign country, a different state, and it can be expired. 

Please upload your income documents below. If you need details on what you need to include for your documents click here: Income Documents