New Patient/Renewal Application Form

New Patient/Renewal Application Form

For questions about your eligibility or this application form, contact frontdesk@greenecareclinic.org or call (434) 985-7000.

Is this a new application, or are you renewing your card?

How did you hear about the Clinic?

What services do you need help with (check all that apply)?

Do you have Medicaid or Medicare?

Do you have a Medicaid application pending?

Do you have a Medicaid Denial Letter?

Please describe any medical issues you are currently experiencing

Name of the Patient

First NameMiddle InitialLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary phone number to contact patient

Area CodePhone Number

Is the primary phone number a cell phone?

Can the primary phone number provided receive text messages?

Is there a secondary phone number where we can contact you?

Area CodePhone Number

Does the secondary phone number receive text messages?

Email

example@example.com

Current age

Date of Birth

Date

Marital status

Gender assigned at birth

With what gender do you identify?

Employment Status

Name of Employer(s)

Employer Phone Number

Area CodePhone Number

Is the patient of Hispanic, Latino, or Spanish origin?

Does the patient need a Spanish Interpreter?

Would you say you are:

Emergency contact name

First NameLast Name

Emergency contact phone number

Area CodePhone Number

Household size (Tax filer + spouse, if married + tax dependents = household size)

Names and ages of any dependents listed on your tax return

Name of spouse (if married)

Did you file a State or Federal tax return last year?

Do you expect to file a State or Federal tax return this year?

Patient's monthly gross income

Please enter your income before taxes, including SSI, Disability, Rent, Royalty, Pensions, Alimony, and/or Family/Friend support.

If married, spouse's monthly gross income

Please enter your income before taxes, including SSI, Disability, Rent, Royalty, Pensions, Alimony, and/or Family/Friend support.

Is there anything else you'd like to know?

Please upload the following documentation: 1) a copy of your ID (e.g., driver's license, state or school ID, voter registration card), 2) proof of residence (e.g., utility bill, bank or credit card statement) and 3) proof of income (e.g., paystub, tax return, unemployment benefit form) OR 4) a signed letter of support from a friend or family member that states that they cover your living expenses (food, shelter, etc.).

Browse Files

Trouble uploading or attaching files? You may email them to frontdesk@greenecareclinic.org. Need more help? Please give us a call at (434) 985-7000.

I hereby grant the Greene Care Clinic permission to verify and discuss my medical and financial information with those directly involved with my care, e.g., physicians, pharmacists, and others as directly relates to my care. Any other request for medical information will require my prior authorization. I hereby grant the Greene Care Clinic permission to share my name and demographic information (i.e., age, marital status) to the Virginia Department of Social Services and other agencies that may be able to provide me with additional assistance. By typing my name and today's date in the space below, I hereby certify that the information I have provided is true and complete.