EIC Registration

Please complete the entire form.

Patient Information

First Name

Middle Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email Address

Primary Language

Date of Birth

Social Security Number

Marital Status

Gender

Female
Male
Transgender: Female to male
Transgender: Male to female

Race (Check all that apply)

Ethnicity

Hispanic/Latino
Non-Hispanic/Non-Latino

Interpreter Needed

Yes
No

Veteran

Yes
No

Home Phone

Cell Phone

Work Phone

Living Situation

Agricultural work (farming, planting, harvesting, raising livestock)

No – I do not primarily work in agriculture
Yes – My primary employment is in agriculture

Employment Status

If employed (check any that apply)

Full Time
Part Time
Permanent
Temporary

If current student

Full-time Student
Part-time Student

Employer information

Name

Guarantor Address (copy)

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Emergency Contact

Name

Guarantor Address (copy) (copy)

Address Line 1

Address Line 2

City

State

Zip Code

Phone (copy)

Phone

Relationship

Responsible Party/ Guarantor (Any patient under 18 must have a responsible party)

Mother
Father
Foster Parent
Guardianship

First Name (copy)

First Name

Middle Name (copy)

Middle Name

Last Name (copy)

Last Name

Address (copy)

Address Line 1

Address Line 2

City

State

Zip Code

Guarantor Social Security Number

Social Security Number

Guarantor Date of Birth

Date of Birth

Guarantor Cell Phone

Home/Cell Phone

Work Phone

Email Address

History of applying for Medicaid or Medicare

Do you have Medicaid or Medicare?

Yes
No

If you do NOT have Medicaid or Medicare, have you ever applied?

Yes
No
N/A

Medical Insurance Information

Do you currently have any medical insurance?

Yes
No

Medical Insurance Name

Medical Insurance - Policy Number

Policy Number

Medical Insurance - Address

Address

Medical Insurance - Group Number

Group Number

Medical Insurance - Phone Number

Phone Number

Medical Insurance - Group Number (copy)

Policy Holder

Medical Insurance - Address (copy)

DOB

Dental Insurance Information

Do you currently have any dental Insurance?

Yes
No

Dental Insurance Name

Dental Insurance - Policy Number

Policy Number

Dental Insurance - Address

Address

Dental Insurance - Group Number

Group Number

Dental Insurance - Phone Number

Phone Number

Dental Insurance - Group Number (copy)

Policy Holder

Medical Insurance - Address (copy) (copy)

DOB

Household Members

(Includes only persons you are related to by birth, marriage, adoption, or a legally defined dependent relationship)

Total Number of Household Members

Name 1

Name

Age 1

Age

Realtionship 1

Relationship

Name 2

Name

Age 2

Age

Realtionship 2

Relationship

Name 3

Name

Age 3

Age

Realtionship 3

Relationship

Name 4

Name

Age 4

Age

Realtionship 4

Relationship

Name 5

Name

Age 5

Age

Relationship 5

Relationship

Name 6

Name

Age 6

Age

Realtionship 6

Relationship

Household Income

Gross Monthly Income you receive from Employment or Unemployment

Gross Monthly Income of your Spouse (or other Adult Family Member)

Dependent Employment Income (All income from full or part time employment, produced by all dependents must be declared as part of the household income.)

Social Security Disability Income

Supplemental Security Income

Child Support

Veteran’s Benefit

Other: Alimony, Retirement Income (Pension), Food Stamps, TANF etc.

Monthly Total

Annual Total

For Ryan White Enrollees

Enrollment questions

Date of initial HIV diagnosis

Organization testing location name

Address of organization

Address Line 1

Address Line 2

City

State

Zip Code

Have you ever received primary care for HIV?

Yes
No

If yes, date of last medical care visit

Practice/Physician Name

Address of Practice/Physician

Address Line 1

Address Line 2

City

State

Zip Code

Phone of Practice/Physician

Upload required enrollment documents including: Proof of Residency, Proof of Income and Proof of Insurance

Click or drag a file to this area to upload.

Client Signature

Clear Signature

Date

When form is complete, please click Submit below.