Note: If the patient/guarantor is married, then spouse’s financial information and signature are required in order to process this application. Name: _____________________________________________________________________ Spouse’s First M.I. Last Address: ____________________________________________________________________ Spouse’s Street City State / Zip Code Number: ______________________________________________________________ Spouse’s Phone Date of Birth: ________________________________________________________________ Spouse’s Social Security Number: _______________________________________________________ Spouse’s Dependents Name Relationship Date of Birth Employment and Insurance Information Patient/Guarantor Spouse Name of employer (If unemployed, write “none”) Are you in school? (If yes, write name of school) Do you have health insurance? (Y/N) If no, is health insurance available through your employer or school? (Y/N) Do you have Medicare? (Y/N) Do you have Medicaid? (Y/N)
Note: If the patient/guarantor is married, then spouse’s financial information and signature are required in order to process this application. Spouse’s Name: _____________________________________________________________________ First M.I. Last Spouse’s Address: ____________________________________________________________________ Street City State / Zip Code Spouse’s Phone Number: ______________________________________________________________ Spouse’s Date of Birth: ________________________________________________________________ Spouse’s Social Security Number: _______________________________________________________ Dependents Name Relationship Date of Birth Employment and Insurance Information Patient/Guarantor Spouse Name of employer (If unemployed, write “none”) Are you in school? (If yes, write name of school) Do you have health insurance? (Y/N) If no, is health insurance available through your employer or school? (Y/N) Do you have Medicare? (Y/N) Do you have Medicaid? (Y/N)