CRXH Intake Form

CRXH Intake Form

Please complete the following form. Required* fields must be completed before submitting application.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Number*
Please enter a valid phone number.
Home Number
Please enter a valid phone number.
Email*
example@example.com
Marital Status:*
Name of Spouse (If applicable):

First NameLast Name
How many live in your home including yourself?*
Are you a Veteran?*

YesNo
Are you Social Security verified disabled?*

YesNo
What year were you verified disabled?
Medical Information
List the name of primary medication you are seeking help with and it dosage info:*
For example: Ozempic (2 mg/1.5 mL) Inject Daily
Are there any other medications that you need financial assistance on? Please list below the name of the medication, its dosage and how often you take it:
For example: Amlodipine 5mg/Twice a Day
List the medications you are currently taking:
For example: Losartan 50mg/Once a Day
Allergies:*

NonePenicillinCodeineSulfaAspirinOther
List all known medication allergies not listed above:
List all your major medical conditions:*
Demographic Information

Health organizations often collect gender, race, and ethnicity data for the purpose of improving public health. Your participation can make a difference. However, this section is optional. The gender section is mandatory, because gender can have an impact on some medications.
Sex assignment at Birth*
How would you describe your race?
Income Information

Please note that some medications allow you to make as much as 400% of the federal poverty level, please indicate below your income level.
Employment Status:*
Did you file a current tax return?*
What year did you file?
What was your annual income?*
Your Monthly Income*
Please indicate below if these wages were from Social Security, Wages, or other:

Social SecurityWagesChild SupportPersonal SupportOther
Spouses Monthly Income
Please indicate below if these wages were from Social Security, Wages, or other:

Social SecurityWagesChild SupportPersonal SupportOther
Other Monthly Income
Please indicate below if these wages were from Social Security, Wages, or other:

Social SecurityWagesChild SupportPersonal SupportOther
Medical Insurance Information

Please indicate if receive any of the following services?
Do you have Medicare? *
If you have a supplement, please list your Health Insurance Company.
Insurance Company Name
Insurance Policy Number
Do you have Medicare D?*
Do you have Medicaid?*
Do you have QMB?*
Do you have Prescription Insurance?*
Do you have Commerical Insurance?*
If yes, who is your Health Insurance Company
Insurance Policy Number
Copy of Your Insurance Card

Please take a front and back photo of your insurance card and upload it here
File Upload (Front)

Please Upload the FRONT of your Insurance Card Here
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File Upload (Back)

Please Upload the BACK of your Insurance Card Here
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Copy of Your Driver's License or ID

Please take a photo of your Driver's License or ID card and upload it here
File Upload

Please Upload a copy of your Drivers License or ID Here
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Important: After you submit this form please return to our website at communityrx.com and complete the other required forms. Thank You.
Signature*

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CRXH Intake Form

Medical Information

Demographic Information

Income Information

Medical Insurance Information

Copy of Your Insurance Card

Copy of Your Driver's License or ID