Providing prescription assistance to Chatham County residents

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    APPLICATION FOR SERVICES

Name  _______________________________________________

Address______________________________________________             _______________________________________________

Phone Number _________________________________________

Date of Birth ___________  

 

Social Security # _____________________  Female    Male

     

Married   Single    Divorced     Widowed

Ethnicity Caucasian   African-American     Hispanic   Other

  

INSURANCE:

Medicaid#______________________(If rejected we need copy of Medicaid letter)    

Medicare#_________________________   VA ____________________

Other    Insurance___________________________________________

             (Name and policy number )

Notes: _________________________________________________________________________

____________________________________________

Primary Care Doctor ____________________________________________ 

Other Doctors:  ________________________________________________

 

FINANCES   (Fill in all monthly income and assets) (indicate pay period-wk, month)  

 

Salary/Wages from:

 

 

Social Security

 

 

SSI (Supplemental Security Income)

 

 

 Pension/Retirement from:

 

 

Unemployment Compensation

 

 

Workers Compensation

 

 

Alimony/child support

 

 

 

 

 

      TOTAL

 

 

TOTAL GROSS INCOME FOR HOUSEHOLD $ ________________

Assets

Checking Acct

 

 

 

Savings Account

 

 

 

CD’s

 

 

 

IRA/retirement/annuity

 

 

 

Other

 

 

 

      TOTAL

 

 

 

 

 

 

MEDICATIONS:

LIST ALL MEDICATIONS  ( prescrtion over-the-counter, herbals, vitamins, etc. that you take)

Name of Medicine

Strength

How often taken?

Prescribing Doctor

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ALLERGIES to medicines ( list each allergy and the reaction you had to that medicine)

  1. _________________________________________________________
  2. _________________________________________________________
  3. _________________________________________________________
  4. _________________________________________________________

 

 

 

 

 

********* I certify that I have NO health insurance including Medicaid, Medicare and VA.  I also state that the information I have provided is true and complete to the best of my knowledge.  I have read the information above and agree with it. I hereby give CCCP permission to verify this information.

 

Signed _________________________________          Date ____________________

 

 

 

 

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# in household _______     200% of poverty _____________

 

ELIGIBLE _______        NOT ELIGIBLE ___ (if not eligible, indicate reason )  ________________________________________________________________________________________________________________________________________________________________________________________________

 

 

Signed ________________________________date________________

         Monthly Income and source                                                  Patient