Thank you for your interest in becoming a client of GoochlandCares.

Our online application process consists of three parts. Each of the three parts of the application must be submitted for your application to be processed by a registration coordinator. This is a protected process and your submissions will be held confidentially. 

	(1) UNIVERSAL REGISTRATION
	(2) SUPPLEMENTAL HOUSEHOLD MEMBERS
	(3) CONSENT AGREEMENTS

Please click NEXT to begin.

General Patient Information

Emergency Contact Details

Demographic Details

Household Information

Employment Information

Insurance Information

Income Information
For the following section, please list the amount of income, before taxes, earned by ALL PERSONS in the family unit. 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.

I, {fullName}, certify that the information herein is an 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.