Patient Information Received Date:__________ Received by: _____________ What language do you speak? English Spanish Other_________ Today’s Date: Legal Last Name Legal First Name, MI What language do you write? English Spanish Other_________ Si Ud. Necesita esta formulario en espaῆol, por favor avisenos. Birthdate Gender Social Security # Are you a US Phone number Other/Former/Maiden Name Citizen? No Yes Male Female Housing Information Are you a veteran? Recently lost Place of birth Highest grade completed (check one) (check one) employment? (city, county, state) Own Rent No (check one) HUD/CHA Homeless Non-combat No Rent Free Group Home Combat Yes Employment Information Employment (check one) Employer Name Employer Phone Number Title Full Time Part Time Self Employed Unemployed Employer Address Date Hired Recently lost employment? Student Disabled No Yes Retired For Dependents Only Name of Parent/Guardian Relationship to Patient Family Size Insurance Information
Patient Information Received Date:__________ Received by: _____________ What language do you speak? English Spanish Other_________ What language do you write? English Spanish Other_________ Si Ud. Necesita esta formulario en espaῆol, por favor avisenos. Today’s Date: Legal Last Name Legal First Name, MI Birthdate Gender Male Female Social Security # Are you a US Citizen? No Yes Phone number Other/Former/Maiden Name Housing Information (check one) Own Rent HUD/CHA Homeless Rent Free Group Home Are you a veteran? (check one) No Non-combat Combat Recently lost employment? (check one) No Yes Place of birth (city, county, state) Highest grade completed Employment Information Employment (check one) Full Time Part Time Self Employed Unemployed Student Disabled Retired Employer Name Employer Phone Number Title Employer Address Date Hired Recently lost employment? No Yes For Dependents Only Name of Parent/Guardian Relationship to Patient Family Size Insurance Information
achc-sliding-fee-scale-application.docx