Patient Qualification Application Full Name First Name Middle name Last Name Birth Date MaleFemale Legal sex SSN —Please choose an option—MarriedSingle Marital Status Full Address Street Address City Zip Code ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY State Langauge Race —Please choose an option—African AmericanCaucasianHispanicAsianOther If you have selected other, please provide race: Are you interested in VIM's Wellness Program? —Please choose an option—YesNo Health Insurance Do you have health insurance? —Please choose an option—YesNo Please select the type: —Please choose an option—MedicaidCHIPMedicareDental InsuranceVA BenefitsOther Health Insurance If you have selected other, please provide name of insurance: Do any family members have health insurance? —Please choose an option—YesNo Please select the type: —Please choose an option—MedicaidCHIPMedicareDental InsuranceVA BenefitsOther Health Insurance If you have selected other, please provide name of insurance: Contact Information Home phone Mobile phone —Please choose an option—YesNo Consent to text? Email address (To register for patient portal) —Please choose an option—HomeWorkMobileEmail 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 YesNo 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