Access Now - Universal Screening Form

1
Select your Clinic* This field is required.
I do not have a clinic
Bon Secours Care-A-Van
Capital Area Health Network
Center for Healthy Hearts
Cheryl Watson Memorial Free Clinic
Chesterfield Health Department
Cornerstone Free Health Clinic
CrossOver Healthcare Ministry
CVHS - Caroline
CVHS - Charles City
CVHS - Downtown Petersburg
CVHS - Hopewell-Prince George
CVHS - King William
CVHS - Louisa
CVHS - Petersburg
CVHS - Westmoreland
Daily Planet Health Services
Dandelion Health
Free Clinic of Powhatan
Gloucester-Mathews Care Clinic
GoochlandCares
Health Brigade
Henrico Health Department
Ledwith-Lewis Free Clinic
Northern Neck-Middlesex Free Health Clinic
Pathways
Richmond Behavioral Health Authority
Richmond City Health District
St. James the Less Free Clinic
2
You must be a patient at one of our participating primary care clinics before you can continue to apply for Access Now. Press submit or click on the link below to be redirected to our web page to find out how to become a patient. If you have any questions, please call us at 804-622-8145.

https://accessnowrva.org/clinic-information/
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Name* This field is required.
First Name
Middle Name
Last Name
4
Preferred Name
5
Date of Birth* This field is required.
Date
Month
Day
Year
6
Social Security Number* This field is required.If no SSN, write "None"
7
Primary Phone Number* This field is required.
8
Secondary Phone Number
9
Email AddressAn email address is required to get confirmation that the form has been submitted.
example@example.com
10
Current Address* This field is required.
Street Address
Street Address Line 2
City
State
Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
11
City/County of Residence* This field is required.
Amelia County
Caroline County
Charles City County
Chesterfield County
Cumberland County
Dinwiddie County
Essex County
Gloucester County
Goochland County
Hanover County
Henrico County
Isle of Wight County
King and Queen County
King George County
King William County
Lancaster County
Louisa County
Mathews County
Middlesex County
New Kent County
Northumberland County
Powhatan County
Prince George County
Richmond County
Southampton County
Surry County
Sussex County
Westmoreland County
City of Colonial Heights
City of Hopewell
City of Petersburg
City of Richmond
Town of Ashland
My county is not listed
12
You must live in one of the counties listed in order to qualify for Access Now. Please contact your clinic to discuss your options.
13
How long have you lived in our service area?* This field is required.
Year(s)
Month(s)
14
Current Living Situation* This field is required.
Own
Rent
Live with family or friends
Live in Shelter
Other
15
Please explain your current living situation* This field is required.
16
Are you traveling in the US on a temporary Visa?* This field is required.
YESNO
17
What type of Visa?
18
Do you have transportation?* This field is required.
YESNO
19
Choose transportation
Busline
Taxi Service
Family or Friends
20
Are you a Veteran of the United States?* This field is required.
YESNO
21
Have you applied for Veteran benefits?
YESNO
22
Were you approved for Veteran benefits?
YESNO
23
Veterans who are eligible for benefits are recommended to seek care at the closest VA medical facility. Please contact your clinic to discuss your options.
24
Do you have Medical Insurance?* This field is required.
YESNO
25
What type of Medical Insurance?
Medicaid - Plan First only
Medicaid
Medicare
Private
Veteran
26
Patients with insurance coverage do not qualify for Access Now. Please contact your clinic to discuss your options.
27
Do you have Prescription Drug Coverage?* This field is required.
YESNO
28
Have you ever applied for Social Security Disability?* This field is required.
YESNO
29
When did you apply for Social Security Disability?
Date
Month
Day
Year
30
What were the results of the application for Social Security Disability?
Denied
Approved
Pending
31
Have you ever applied for Medicaid?* This field is required.
YESNO
32
When did you apply?
Date
Month
Day
Year
33
What were the results of the application?
Denied
Approved
Pending
34
Contact your clinic once you receive the results of your Medicaid application. If you become approved for full coverage Medicaid, you will not be eligible for the Access Now program.
35
Patients with insurance coverage do not qualify for Access Now. Please contact your clinic to discuss your options.
36
When and where did you last receive Medical care?
37
Do you need medical care because of a work injury or car accident?* This field is required.
YESNO
38
If the medical care needed is the result of an accident we may need additional information prior to scheduling an appointment.
39
What is your primary language?* This field is required.
English
Spanish
Portuguese
Arabic
Other
40
What is your Language?
41
Do you have access to an interpreter?
No, but I do not need one
No, I need one
Yes
42
Race* This field is required.
American Indian/Alaskan Native
Asian
Black or African-American
Native Hawaiian/Pacific Islander
White
Other
43
Race/Other
44
What is your ethnicity?* This field is required.
Hispanic or Latino
Non-Hispanic or Latino
45
In what country where you born?
46
Marital Status* This field is required.
Married
Partnered
Single
Divorced
Legally Separated
Widowed
47
Highest Education Level* This field is required.
None
Less than High School
High School Graduate/GED
Some College
College Graduate
Technical/Vocational School
Community College
48
Gender at Birth* This field is required.
Female
Male
49
Gender Identity
Male
Female
FTM/TransMan
MTF/TransFemale
Genderqueer
Non-binary
Transgender
Decline to Answer
Something Else
50
Gender Identity write-in
51
Sexual Orientation
Lesbian
Gay
Queer
Straight/Heterosexual
Bisexual
Decline to Answer
Something Else
52
Sexual Orientation write-in
53
Preferred Pronouns
He/Him
She/Her
They/Them
54
Emergency Contact Name/Relationship
55
Emergency Contact Phone Number
56
Household InformationPlease list the names and relationships of the patient's family unit living in the house. For Relationship to Patient (Self, Spouse, Child, Parent, Relative, Other)
Name of Family Member
Date of Birth
Relationship to Patient
Patient
Family Member 1
Family Member 2
Family Member 3
Family Member 4
Family Member 5
Family Member 6
Family Member 7
Family Member 8
Patient
Family Member 1
Family Member 2
Family Member 3
Family Member 4
Family Member 5
Family Member 6
Family Member 7
Family Member 8
Name of Family Member
Date of Birth
Relationship to Patient
Name of Family Member
Date of Birth
Relationship to Patient
Name of Family Member
Date of Birth
Relationship to Patient
Name of Family Member
Date of Birth
Relationship to Patient
Name of Family Member
Date of Birth
Relationship to Patient
Name of Family Member
Date of Birth
Relationship to Patient
Name of Family Member
Date of Birth
Relationship to Patient
Name of Family Member
Date of Birth
Relationship to Patient
Name of Family Member
Date of Birth
Relationship to Patient
1 of 9
57
Did you file Taxes in the last year?
YESNO
58
If you claimed a person who does not live in your household, please list them here:
59
Did someone else claim you as a dependent on their tax return?
YESNO
60
Was it your spouse?
YESNO
61
Type the Name and Relationship of who claimed you in their taxes* This field is required.
62
Upload the file with the taxes here* This field is required.Note: Taxes must be signed by person(s) filing taxes
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
63
Patient's Employment Status
Full-time
Part-time
Seasonal
Self-employed
Unable to work/Living with a disability
Retired
Student
Dependent
Unemployed
64
List your Employer(s)For Frequency of Pay (Weekly, Bi-Weekly, Bi-Monthly, Monthly) For Time Employed There (How long in months/years have you been working at that place?)
Employer Name
Frequency of Pay
Time Employed There
Input 1
Input 2
Input 3
Input 4
Input 1
Input 2
Input 3
Input 4
Employer Name
Frequency of Pay
Time Employed There
Employer Name
Frequency of Pay
Time Employed There
Employer Name
Frequency of Pay
Time Employed There
Employer Name
Frequency of Pay
Time Employed There
1 of 4
65
How long have you been unemployed?
I have never worked
Less than a month
1 to 3 months
4 to 6 months
7 to 9 months
10 to 12 months
Over a year
66
How do you provide food, shelter and other living expenses for yourself/family?
Savings
Support from friends/family
SNAP
Unemployment benefits
Child Support
Social Security
Disability Income
Retirement Income
67
Spouse's Employment Status
Full-time
Part-time
Seasonal
Self-employed
Unable to work/Living with a disability
Retired
Student
Dependent
Unemployed
68
List your Spouse's Employer(s)For Frequency of Pay (Weekly, Bi-Weekly, Bi-Monthly, Monthly) For Time Employed There (How long in months/years have your spouse been working at that place?)
Employer Name
Frequency of Pay
Time Employed There
Input 1
Input 2
Input 3
Input 4
Input 1
Input 2
Input 3
Input 4
Employer Name
Frequency of Pay
Time Employed There
Employer Name
Frequency of Pay
Time Employed There
Employer Name
Frequency of Pay
Time Employed There
Employer Name
Frequency of Pay
Time Employed There
1 of 4
69
How long has your spouse been unemployed?
My spouse has never worked
Less than a month
1 to 3 months
4 to 6 months
7 to 9 months
10 to 12 months
Over a year
70
Are you or any member of your household self-employed?* This field is required.
YESNO
71
List Members of your household including yourself that are self-employedFor Relationship to Patient (Self, Spouse, Child, Parent, Relative, Other)
Name of Person who receives this income
Relationship to Patient
1
2
3
4
1
2
3
4
Name of Person who receives this income
Relationship to Patient
Name of Person who receives this income
Relationship to Patient
Name of Person who receives this income
Relationship to Patient
Name of Person who receives this income
Relationship to Patient
1 of 4
72
Upload COMPLETE TAX form(s) including business taxes from the most recent tax yearNote: Taxes must be signed by person(s) filling taxes
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
73
Are you or any member of your household employed by a company or employer?* This field is required.
YESNO
74
List Members of your household including yourself that are employedFor Relationship to Patient (Self, Spouse, Child, Parent, Relative, Other)
Name of Person who receives this income
Relationship to Patient
1
2
3
4
1
2
3
4
Name of Person who receives this income
Relationship to Patient
Name of Person who receives this income
Relationship to Patient
Name of Person who receives this income
Relationship to Patient
Name of Person who receives this income
Relationship to Patient
1 of 4
75
Upload 4 most recent pay stubs, signed letter from employer (on company letterhead or notarized) or self declaration of income
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
76
Are you or any member of your household receiving unemployment benefits?* This field is required.
YESNO
77
List Members of your household including yourself that receive unemployment benefitsFor Relationship to Patient (Self, Spouse, Child, Parent, Relative, Other)
Name of Person who receives this income
Relationship to Patient
1
2
3
4
1
2
3
4
Name of Person who receives this income
Relationship to Patient
Name of Person who receives this income
Relationship to Patient
Name of Person who receives this income
Relationship to Patient
Name of Person who receives this income
Relationship to Patient
1 of 4
78
Upload Unemployment Benefit Letter
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
79
Are you or any member of your household receiving Social Security?* This field is required.
YESNO
80
List Members of your household including yourself that receive Social SecurityFor Relationship to Patient (Self, Spouse, Child, Parent, Relative, Other)
Name of Person who receives this income
Relationship to Patient
1
2
3
4
1
2
3
4
Name of Person who receives this income
Relationship to Patient
Name of Person who receives this income
Relationship to Patient
Name of Person who receives this income
Relationship to Patient
Name of Person who receives this income
Relationship to Patient
1 of 4
81
Upload Social Security benefit letter or bank statement if direct deposited
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
82
Are you or any member of your household receive a Pension, Retirement Income or Disability Income?* This field is required.
YESNO
83
List Members of your household including yourself that receive Pension, Retirement Income or Disability IncomeFor Relationship to Patient (Self, Spouse, Child, Parent, Relative, Other)
Name of Person who receives this income
Relationship to Patient
1
2
3
4
1
2
3
4
Name of Person who receives this income
Relationship to Patient
Name of Person who receives this income
Relationship to Patient
Name of Person who receives this income
Relationship to Patient
Name of Person who receives this income
Relationship to Patient
1 of 4
84
Upload Pension/Retirement/Disability letter or complete bank statement if direct deposited
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
85
Does any member of your household receive SNAP benefits?* This field is required.
YESNO
86
Upload SNAP Letter
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
87
Does any member of your household receive Child Support?* This field is required.
YESNO
88
List Members of your household that receives Child SupportFor Relationship to Patient (Self, Spouse, Child, Parent, Relative, Other)
Name of Person who receives this income
Relationship to Patient
1
2
3
4
1
2
3
4
Name of Person who receives this income
Relationship to Patient
Name of Person who receives this income
Relationship to Patient
Name of Person who receives this income
Relationship to Patient
Name of Person who receives this income
Relationship to Patient
1 of 4
89
Upload Court ordered document or letter from non-custodial parent
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
90
Does any member of your household own rental or investment property?* This field is required.
YESNO
91
List Members of your household that own a rental or investment propertyFor Relationship to Patient (Self, Spouse, Child, Parent, Relative, Other)
Name of Person who receives this income
Relationship to Patient
1
2
3
4
1
2
3
4
Name of Person who receives this income
Relationship to Patient
Name of Person who receives this income
Relationship to Patient
Name of Person who receives this income
Relationship to Patient
Name of Person who receives this income
Relationship to Patient
1 of 4
92
Upload Rental agreement/documentation listing income amount
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
93
Does any member of your household have any other source of income?* This field is required.
YESNO
94
Upload current statement(s)/document(s) of Alimony, Stocks, Bonds, CD’s additional property, etc* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
95
No one in my household , including myself, receives any income* This field is required.
TrueFalse
96
If your household is claiming no income you must have the person providing your food, shelter, and/or daily living expenses sign and date a notarized letter indicating which type of assistance they are providing. If living off savings, sign and date a letter explaining your situation.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
97
Certification Statement* This field is required.I CERTIFY that the information herein is an accurate and complete statement of my financial status. 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.
98
Declaración de certificación* This field is required.CERTIFICO que la información aquí mencionada es la verdad y correcta. Entiendo que esta información está sujeta a verificación y que si mi situación financiera cambia o si obtengo seguro médico, será reevaluado si soy elegible o no. Entiendo que es mi responsabilidad el notificar a LA CLÍNICA de cualquier cambio en mi situación financiera. Autorizo que mi información financiera sea compartida (incluyendo No. de SS) con proveedores médicos, compañías farmacéuticas, Access Now y/o sus agentes para determinar si soy elegible para asistencia financiera, para medicamentos y verificación durante auditorias rutinarias. Este documento solamente tiene como propósito verificar si califico para recibir beneficios, no garantiza que yo reciba algún tipo de beneficios de alguna parte. LA CLÍNICA no ofrece garantía alguna. Entiendo que la falsificación de la información presentada pondra en peligro la consideración de mi aplicación para el programa.
99
Cerfiticado de declaração* This field is required.Eu CERTIFICO que a informação aqui contida é uma declaração precisa e completa da minha situação financeira. Entendo que se a minha situação financeira mudar ou se obtiver plano de saúde, minha elegibildade será reavaliada. Entendo que é minha responsabilidade notificar A CLÍNICA sobre qualquer mudança na minha situação financeira. Autorizo a liberação de meus dados financeiros (incluindo Número de Seguro Social) a RX Partnership, empresas farmacêuticas e Access Now e/ou seus agentes para determinar minha elegibilidade para assistência financeira para medicamentos e verificação durante auditorias rotineiras. Esta revisão é somente uma vefiricação na elegibilidade. Não é uma garantia que receberei benefícios de qualquer fonte. A CLÍNICA não oferece tais garantias. Entendo que a falsificação das informações enviadas prejudicará na minha consideração para o programa.
100
Certification Statement* This field is required.I CERTIFY that the information herein is an accurate and complete statement of my financial status. 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.
101
Certification Statement* This field is required.I CERTIFY that the information herein is an accurate and complete statement of my financial status. 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.
102
Certification Statement* This field is required.I CERTIFY that the information herein is an accurate and complete statement of my financial status. 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.
103
Certification Statement* This field is required.I CERTIFY that the information herein is an accurate and complete statement of my financial status. 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.
104
Certification Statement* This field is required.I CERTIFY that the information herein is an accurate and complete statement of my financial status. 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.
105
Patient's Signature
Clear
Should be Empty: