Patient Eligibility Application

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.
Responsible Party: Full Name*

First NameM.I.Last Name
Social Security Number*
Date of Birth*

MonthDayYear
Primary Phone Phone*
Please enter a valid phone number.
Email Address
example@example.com
Relationship to Patient
INSURANCE INFORMATION
Preferred Pharmacy Name
Pharmacy Address

Street Address

Street Address Line 2

CityState

Zip Code
Pharmacy Phone Number*
Please enter a valid phone number.
PRIMARY Insurance Company Name*
Policy Holder: Full Name*

First NameLast Name
Policy Holder: Social Security Number*
Policy Holder: Date of Birth*

MonthDayYear
Patient Relationship to Policy Holder*
SECONDARY Insurance Company Name
Policy Holder: Full Name

First NameLast Name
Policy Holder: Social Security Number
Policy Holder: Date of Birth

MonthDayYear
Patient Relationship to Policy Holder
Please upload an image of the FRONT of your card.*

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Please upload an image of the BACK of your card.*

Files may be loaded as pdf, doc, docx, html, zip, jpg, jpeg, png, and/or gif
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Please upload a picture of your photo ID. *

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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.
Signature of Patient [use your mouse, track pad or finger on touchscreen]*

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Submission Date*

MonthDayYear
Should be Empty: