Medicaid Patient Registration

INSURANCE INFORMATION

Preferred Pharmacy Name
Pharmacy Phone Number
Please enter a valid phone number.
Pharmacy Address

Street Address

Street Address Line 2

City State

Zip Code
PRIMARY Insurance Company Name *
Policy Holder: Full Name *

First Name Last Name
Policy Holder: Member ID *
Policy Holder: Date of Birth *

Month Day Year
Patient Relationship to Policy Holder *
SECONDARY Insurance Company Name
Policy Holder: Full Name

First Name Last Name
Policy Holder: Member ID
If no SSN, write "None"
Policy Holder: Date of Birth

Month Day Year
Patient Relationship to Policy Holder
Please upload an image of the FRONT of your insurance card. *

Files may be loaded as pdf, doc, docx, html, zip, jpg, jpeg, png, and/or gif
Cancel of
Please upload an image of the BACK of your insurance card. *

Files may be loaded as pdf, doc, docx, html, zip, jpg, jpeg, png, and/or gif
Cancel of
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 CROSSOVER HEALTHCARE MINISTY 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 CROSSOVER HEALTHCARE MINISTY offers no such guarantees. I understand that falsification of information submitted will jeopardize my consideration for the program.
Please upload a copy of your ID card – state issued license or ID card, federal ID card, passport, consular ID, permanent resident ID, etc. *

Files may be loaded as pdf, doc, docx, html, zip, jpg, jpeg, png, and/or gif
Cancel of
Signature of Patient [use your mouse, track pad or finger on touchscreen] *

[to sign you may use your mouse, track pad or finger on touchscreen Clear
Submission Date *

Month Day Year
Should be Empty:

	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