Medicaid Patient Registration

PATIENT INFORMATION

What is your primary language? *

English Spanish Portuguese Arabic Other
Do you have access to an interpreter?

Yes No
Physician or Pediatrician Name
Phone Number
Employers Name
Phone Number
Emergency Contact Name *

First Name Last Name
Emergency Contact Phone Number *
Relationship to Patient *

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.
Relationship to Patient *
Responsible Party Full Name *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
Social Security Number *
If no SSN, write "None"
Email Address
example@example.com
Primary Phone Number *
Address *

Street Address

Street Address Line 2

City State

Zip Code
May we leave a message regarding the patients medical care and test results? *

Yes No
Preferred Pharmacy
Pharmacy Address

Street Address

Street Address Line 2

City State

Zip Code

INSURANCE INFORMATION

PRIMARY Insurance Company Name *
Policy Holder: Full Name *

First Name Last Name
Patient Relationship to Policy Holder *
Policy Holder: Date of Birth *

Month Day Year
Policy Holder: Social Security Number *
If no SSN, write "None"
SECONDARY Insurance Company Name
Policy Holder: Full Name

First Name Last Name
Patient Relationship to Policy Holder
Policy Holder: Date of Birth

Month Day Year
Policy Holder: Social Security Number
If no SSN, write "None"
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
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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
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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.
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
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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: