First Name
Middle name
Last Name
Birth Date
MaleFemale Legal sex
SSN
—Please choose an option—MarriedSingle Marital Status
Street Address
City
Zip Code
ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY State
Langauge
Race —Please choose an option—African AmericanCaucasianHispanicAsianOther [group otherace-selected] If you have selected other, please provide race: [/group]
Are you interested in VIM's Wellness Program? —Please choose an option—YesNo
Do you have health insurance? —Please choose an option—YesNo [group insured-selected] Please select the type: —Please choose an option—MedicaidCHIPMedicareDental InsuranceVA BenefitsOther Health Insurance [group other-selected] If you have selected other, please provide name of insurance: [/group] [/group]
Do any family members have health insurance? —Please choose an option—YesNo [group faminsured-selected] Please select the type: —Please choose an option—MedicaidCHIPMedicareDental InsuranceVA BenefitsOther Health Insurance [group famother-selected] If you have selected other, please provide name of insurance: [/group] [/group]
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 [group workphone-selected] If you have selected work number, please provide phone number: [/group]
Emergency Contact Name
Relationship
Phone number
[field_group household] First, last name
DOB
YesNo Contributes to Income
[/field_group]
Please visit Patient Eligibility for more information.
Income Verification
Photo Identification
Proof of Proof of Residency/Employment
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.
Today's Date [signature* signature-patient color:#000000 backcolor:#dddddd width:400 height:200]
