A Step Ahead Foundation Tri-Cities Disclosure Form
UNINSURED? Complete this confidential form, and A Step Ahead will reimburse this office for your appointment, IUD or implant, and, later, the cost of device removal. INSURED? Complete this confidential form, and A Step Ahead will reimburse this office for any portion of your IUD or implant appointment that’s not covered by insurance. That includes a co-pay or deductible. Once your form is on file, you can rest assured that the cost of device removal will be covered, even if your insurance status changes. If you do not want your insurance processed, please let a clinic staff person know.
Name
First Name
Last Name
Email
example@example.com
May we contact you via email?
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Answers to the following questions do not affect your eligibility for A Step Ahead free birth control.
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
May we contact you via phone/text?
Yes
No
How did you hear about A Step Ahead?
Friend/Family
Clinic
Online
Flyer
Event/Class
Other
Birthday
-
Month
-
Day
Year
Date
Are you a student?
Yes
No
Are you:
Hispanic
Non-Hispanic
Do you identify as:
Asian
Biracial
Black
Latina/Latinx
Native American
White
Other
Are you employed?
Yes
No
If yes, employer:
Insurance Status
None
Private
TennCare
Coverkids
Other
If other, please specify:
Are you unable to use your insurance because of (check all that apply):
Co-pay/deductible too high
insurance doesn't cover IUD/Implant/Depo/pill
Confidentiality
Other
If other, please specify:
Highest level of education completed:
Middle school or less
Some high school
Graduated high school
Some college/vocational school
Associates degree
Bachelor's degree or higher
Number in your household including you:
Estimated household income this year:
Less than $10,000
$10,000 - $24,000
$24,000 - $35,000
$35,000 - $45,000
$45,000 - $55,000
$55,000 - $75,000
higher than $75,000
Relationship status:
Single
Married
Lives with partner
Separated
Divorced
Widowed
Past birth control methods used (check all that apply):
None
Condoms
Depo Provera
Patch
Ring
Withdrawal (pull out)
Hormonal IUD (ex Mirena, Kyleena, etc)
Non Hormonal IUD (Paragard)
Rhythm Method/Fertility Awareness
Implant (Nexplanon)
The Pill
Other
Current birth control
Number of prior pregnancies
Number of planned pregnancies
Number of live births
Ages of children:
Date of last gynecological check-up:
Disclosure Statement
I understand that I am seeking financial assistance from A Step Ahead Foundation of Tri-Cities (ASAFTC) for “Covered Services,” defined as the standard insertion and removal, through an ASAFTC partner physician or clinic, of ASAFTC-accepted reversible birth control that lasts for a maximum of five (5) or (10) years. I give my permission for any unpaid medical bills related to Covered Services in my name to be paid by ASAFTC. I acknowledge that ASAFTC is only providing financial assistance and is not providing any medical advice, medical treatment, or medical products, nor providing any recommendations or warranty regarding my selection of a medical provider for Covered Services.
Date
-
Month
-
Day
Year
Date
Signature
Type of birth control you are interested in:
Submit
Should be Empty: