• Thank you for interest in becoming a client at GoochlandCares.

    Before your application can be reviewed and processed by our Registration Office, it is essential that you complete and sign all sections of the form.

    Please note that your application will not be officially submitted until you click the 'SUBMIT' button at the end of the form. Ensure you review all information before submitting.

    Please note, if you are trying to apply for Transportation services only, please go back to the website and fill out the application on the Transportation page.

    To continue with your application, click the NEXT button below to proceed to the following section.

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  • General Patient Information

  • Format: (000) 000-0000.
  • DOB: Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you:*
  • City/County of Residence:*
  • Do you:*
  • Are you traveling in the U.S. on a temporary visa?*

  • Demographic Details

  • What is your marital status?*
  • What is your highest level of education?*
  • Would you say that you are:*
  • What is your ethnicity?*
  • What is your primary language?*
  • Do you have access to an interpreter?*
  • Are you a veteran of the United States?*
  • If yes, are you eligible for benefits?*
  • If yes, have you applied for benefits?*

  • Emergency Contact Information

  • Format: (000) 000-0000.

  • Household Information

  • Did you file taxes last year?*
  • If no, could someone claim you on their taxes?*
  • If you did file taxes last year, did you claim a person on your taxes that does not live in your household?*
  • Please list the names and relationships of everyone listed on your tax form: *
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  • Is there anyone else living in your household that is not claimed on your taxes?*
  • Please list the names and relationships of your family unit living in the house, not listed on your taxes or SNAP Letter. *
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  • Please list the names and relationships of your family unit living in the house, if you were to file your taxes or file for SNAP Benefits. *
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  • Is there anyone else living in your household that you would not include if you were to file taxes or for SNAP Benefits?*
  • Please list the names and relationships of your family unit living in the house, not listed on your taxes or SNAP Letter. *
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  • Employment Information

  • What is your employment status?*
  • What is your spouse's employment status?*
  • Do you receive SAA?
  • Do they receive SAA?

  • Insurance Information

  • Do you have medical insurance?*
  • Do you have dental insurance?*
  • If yes, what type?*
  • Do you have Prescription Drug Coverage?*
  • Have you ever applied for Social Security Disability?*
  • Have you ever applied for Medicaid?*
  • Is your healthcare need the result of an accident?*
  • Was the accident work-related?*

  • Income Information

  • Do you receive any income? This could be the following types of income: wages/salary/self-employment, child support/alimony, interest/dividends, disability benefits, retirement benefits, Social Security Income, Unemployment benefits, and any other type of income. Incomes from loans does not apply.*

  • For the following section, please list the amount of income, before taxes, earned by ALL PERSONS in the family unit. This also includes any adult children over 18 years old living in the household. If no income is received for anyone in the household, please still list them and put "0" in the amount. Include the following types of income: wages/salary/self-employment, child support/alimony, interest/dividends, disability benefits, retirement benefits, Social Security Income, Unemployment benefits, and any other type of income. Do not include income from loans

  • *
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  • Do you receive SNAP (Food Stamp) benefits?*
  • Please check which types of proof of income that can be provided to GoochlandCares to verify income.*
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  • I, {name}, 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 GoochlandCares 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 GoochlandCares offers no such guarantees. I understand that falsification of information submitted will jeopardize my consideration for the program.

    I understand that once a client record is created, GoochlandCares may be required to retain certain information to comply with federal, state, contractual, audit, insurance, safeguarding, or operational requirements. Requests for deletion of information will be reviewed in accordance with organizational policy and applicable law.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Consent to Contact

  • {name}

    {address}

    {phoneNumber}

    {email}

  • Please indicate how we can contact you via:*
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  • Should we block our number when we call?*
  • Can we leave a message?*

  • Consent to Exchange Information

  • I understand that different agencies provide related services. I understand that any exchange of information will be used to determine my eligibility, resolve a family crisis, or improve my health care at GoochlandCares. I understand that I will be shown what has been shared, as well as why, when and with whom, at any time I request. I understand that I may withdraw this consent at any time by notifying GoochlandCares in writing.

    *By signing this form, I give my consent for GoochlandCares to obtain information (including financial information) and/or provide information to the organizations/businesses listed below.

  • *
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  • For Clinic and Dental Patients:*
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  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • You will now be directed to the Basic Human Needs Assessment. This assessment will help identify which programs may be beneficial to your needs. Your application will not be considered complete without this form. 

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