Please only fill out this form if you have Medicaid. If you do not have insurance, please visit our eligibility page to review your enrollment options.

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.