Project Access Re-enrollment Application

Project Access Re-enrollment Application
Re-enrollments must be completed within 30 days of your expiration date. You must provide current proof of address, current proof of all income or assistance payments (FS, SS, AHA, etc), current bank or paycard statement, and a current WG15 for all household members 16 and older. Please allow 10 days for proccessing competed applications. It is your responsibility to ensure that this form is completed (both sides) and returned along with all necessary documentation to avoid lapse in coverage. We ask that you do not make any appointments until your new cards are received.
Name*

First NameMiddle NameLast NameSuffix
Birth Date*

MonthDayYear
Date
I have read the term and conditions. Signature

Clear
Social Security Number*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Financial Resources - (Must list ALL income, assistance payments, etc.)

I hereby apply for re-enrollment into RCMS Project Access. By signing below, I understand that if I fail to comply with the program guidelines (i.e. keep scheduled appointments, provide required documentation, report changes to income, address, etc.) or fail to provide full and accurate information, my application will be automatically denied and I will not be eligible to re-apply for benefits under RCMS Project Access in the future due to their Zero Tolerance Policy.
Patient's Signature*

Clear
Date*

MonthDayYear
Date
Witness (only if Patient is unable to sign)

Clear
Relation to Patient

Project Access Re-enrollment Application Continued

Please Answer the Following Questions
1) Has your address or phone number changed in the last 6 (six) months?
If so, please list your new information:
2) Has your marital status changed in the last 6 (six) months?
If so, please explain:
3) Has the number of people in your home changed in the last 6 (six) months?
If so, please explain:
4) Has your monthly earnings (before taxes) changed from the amount you last reported on your application or previous re-enrollment?
If so, please explain:
5) If you receive any State Program benefits (Food Stamps, Housing, TANF, CCA), have you had any changes in the last 6 (six) months?
If so, please explain:
6) If you received child support, SSI, SSA, RSDI, UCB or VA benefits, has this amount changed in the last 6 (six) months?
If so, please explain:
7) Have you applied for Insurance, Medicaid, Medicare, Disability or have you had any workers comp or accident claims filed within the last 6 (six) months?
If so, please explain:
8) Please explain any other changes that you may have had in your household or financial information within the last 6 (six) months.
Patient's Initials*
Please upload the all necessary documentation.

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Should be Empty:

Project Access Re-enrollment Application Continued