Healthcare Program CA Application

HEALTHCARE PROGRAM CA APPLICATION

Program Selection

Select the healthcare program for which you are applying. Selection determines eligibility review and documentation requirements.

Primary Care Enrollment
Prescription Assistance
Family Planning Services
Sliding Fee / Financial Assistance

Applicant Information

Date of Birth:   Gender:

Household & Income

Household size (total persons in household):    Monthly gross household income: $

Emergency Contact

Insurance Information

Do you currently have health insurance?   Yes No

Medical History

Consent for Enrollment & Treatment

By checking the consent box and signing below, the applicant authorizes enrollment in the selected Healthcare Program CA services. The applicant authorizes clinicians and program administrators to provide routine and emergency medical care, perform diagnostic tests, and administer medications as indicated. The applicant understands that all care is subject to professional clinical judgment and that no guarantee of specific outcomes is given.

The applicant acknowledges the right to ask questions, to refuse or withdraw consent at any time, and to request alternative treatments when medically appropriate. Withdrawal of consent may affect eligibility for program benefits.

I consent to enrollment and to receive treatment and services as described above.

Authorization to Release Information & Assignment of Benefits

I authorize the release of medical, billing and eligibility information necessary to determine program eligibility, coordinate care, and process claims. I authorize the program and its agents to obtain records from other health care providers and to share information with payers, case managers, and mutually authorized health professionals for purposes of treatment, payment, and healthcare operations.

I assign to the program any insurance or third-party benefits payable for services rendered. I understand that I remain financially responsible for charges not covered by insurance or program benefits.

I authorize release of information and assignment of benefits as described above.

Authorization expiration date (if not indefinite):

Privacy Notice / HIPAA Acknowledgment

I acknowledge that I have received or been offered a copy of the program's Notice of Privacy Practices that explains how my medical information may be used and disclosed and how I can access this information. I understand that the program may use and disclose protected health information for treatment, payment, and healthcare operations as permitted by law.

I acknowledge receipt of the Privacy Notice and understand my rights under applicable privacy laws.

Applicant Certification

I certify under penalty of perjury that all information provided on this application is true and complete to the best of my knowledge. I understand that knowingly providing false information or withholding material facts may result in denial of enrollment, termination of benefits, or other legal action.

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