• Alabama Department of Senior ServicesSenioRx FY27 Participant Enrollment Form

  • Please complete and return to your Area Agency on Aging (AAA). Call 1-800-AGELINE (1-800-243-5463) for the correct mailing address.

  • PARTICIPANT INFORMATION

    Shaded area required for ADSS. Other information as required by medication assistance programs.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Birthdate: MM / DD / YYYY
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender:
  • Ethnicity:
  • Race:

  • EMERGENCY CONTACT INFORMATION

    Please provide name of a person to contact in an emergency.
  • Relationship to participant:
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Are you a legal resident of the U.S.?
  • Employment Status:
  • Are you a veteran or veteran's spouse/widow?
  • Marital Status:
  • Spouse's Birthdate:
     - -
    2 digit month, 2 digit day, 4 digit year

  • SOURCES OF INCOME: .

    We MUST HAVE a copy of proof(s) of income for EVERYONE who lives in your household.

  • TOTAL MONTHLY INCOME $ | TOTAL ANNUAL INCOME $

  • MEDICAL INFORMATION

  • Are you currently enrolled in another prescription assistance program or discount program?
  • Are you enrolled in:
  • Do you have any health insurance coverage (other than Medicare)?
  • Medical Conditions: (Check all that apply)
  • Medication Allergies: (Check all that apply)
  • If you have more than one prescribing physician, please attach a list with each doctor's name, address, and telephone number. Alabama SenioRx cannot guarantee that you will receive the medicines requested.
    Rows

  • I hereby state that the information I have given is correct to the best of my knowledge and the Alabama SenioRx program has my permission to obtain and release information as deemed necessary to obtain my medication. I understand the Alabama SenioRx program cannot guarantee assistance. I understand that omitting or falsifying information is grounds for denial of services.

  • Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Statement of Confidentiality: The information recorded on this form is required for the statistical and reporting requirements for State and Community Programs under the Older Americans Act of 1965, as amended [Public Law 8973], and is not to be used for any other purpose in any form which could identify the individual without the individual's knowledge of the specific use and the individual's specific authorization for such use.
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  • Should be Empty: