Patient Qualification Application

    Full Name


    First Name


    Middle name


    Last Name


    Birth Date


    Legal sex


    SSN


    Marital Status

    Full Address


    Street Address


    City


    Zip Code


    State

    Langauge

    Race

    If you have selected other, please provide race:

    Are you interested in VIM's Wellness Program?

    Health Insurance

    Do you have health insurance?

    Please select the type:

    If you have selected other, please provide name of insurance:

    Do any family members have health insurance?

    Please select the type:

    If you have selected other, please provide name of insurance:

    Contact Information


    Home phone


    Mobile phone


    Consent to text?


    Email address (To register for patient portal)


    Contact Preference

    If you have selected work number, please provide phone number:

    Emergency Contact Information


    Emergency Contact Name


    Relationship


    Phone number

    Full name and date of birth of each person who is part of your household, including spouse, partner, other adults and/or children supported by the household income. Please also indicate if each person contributes to the household income.


    First, last name


    Relationship


    DOB


    Contributes to Income

    Upload Documents

    Please visit Patient Eligibility for more information.

    Income Verification

    Photo Identification

    Proof of Proof of Residency/Employment

    Patient Attestation and Signature

    I certify that the information I have provided in my application is complete, and true to the best of my knowledge and belief. I further understand that it is my responsibility to notify the clinic of any changes in my financial situation or insurance status. I give permission to verify my income through the Department of Social Services, Social Security Administration, my employer, Veterans Administration and any other company, business or organization from which I receive income. By signing the enclosed application, I authorize representatives of Volunteers in Medicine Clinic Hilton Head Island to share this information with auditors or pharmaceutical companies as required.

    Signature

    Today's Date