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

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    PATIENT INFORMATION
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    ADDITIONAL INFORMATION
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    HOUSING & LIVING SITUATION
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    RESPONSIBLE PARTY INFORMATION
  • If the patient is a minor (under the age of 18), the parent or guardian bringing in the patient will be listed as the guarantor. Please complete the following section as the Responsible Party.

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    INSURANCE INFORMATION
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  • 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.

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