Universal Registration Form

Thank you for your interest in becoming a client of GoochlandCares.

Our online application process consists of three parts. Each of the three parts of the application must be submitted for your application to be processed by a registration coordinator. This is a protected process and your submissions will be held confidentially.

	(1) UNIVERSAL REGISTRATION
	(2) SUPPLEMENTAL HOUSEHOLD MEMBERS
	(3) CONSENT AGREEMENTS

Please click NEXT to begin.

General Patient Information
Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Gender
Phone Number

Area CodePhone Number
Type of Phone
Email Address *We will contact you at this email regarding your registration.
example@example.com
Physical Address

Street Address

Street Address Line 2

CityState

Zip Code
County of Residence
Type of Housing
How long have you lived in the greater Richmond area?
(i.e. years / months)
Are you traveling in the United States on a temporary Visa?
Do you have transportation?
Emergency Contact Details
Emergency Contact - Full Name

First NameLast Name
Relationship to Patient
(i.e. partner, mother/father, son/daughter...)
Phone Number

Area CodePhone Number
Demographic Details
What is your marital status?
Would you say you are:
What is your ethnicity?
What is your highest level of education?
What is your primary language?

Other
Do you have access to an interpreter?
Household Information

Please list the names and relationships of the patient's family unit living in the house. (please include everyone listed on your tax form)

Rows	Name of Family Member in Household	Date of Birth (mm/dd/yyyy)	Relationship to Patient (ex: self, mother, son)	Social Security Number (If no, SSN, put "none")
1
2
3
4
5
6

Did you file taxes in the last year?
If NO, did someone else claim you on their tax return?
If you claimed a person on your taxes who does not live in the household, please list those persons here:
Employment Information
What is your Employment Status?
Are you a veteran of the United States?
How long have you been unemployed?
(i.e. years / months)
How long have you been unemployed?
(i.e. years / months)
Are you eligible for benefits?
Have you applied for benefits?
Place of Employment
Time Employed
(i.e. years / months)
[WORK] Phone Number

Area CodePhone Number
What is your spouse’s employment status?
How long has your spouse been unemployed?
(i.e. years / months)
What is your spouse’s place of employment?
Spouse’s Time Employed
(i.e. years / months)
Spouse’s Work Phone Number

Area CodePhone Number
Insurance Information
Do you have MEDICAL Insurance?
Type of MEDICAL Insurance
Do you have DENTAL Insurance?
Do you have PRESCRIPTION DRUG COVERAGE?
Have you ever applied for SOCIAL SECURITY DISABILITY?
Effective Date of Approval

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Have you ever applied for MEDICAID?
If YES, date applied

MonthDayYear
2 digit month, 2 digit day, 4 digit year
When and where did you last receive healthcare services?
Is your healthcare need the result of an accident?
Was the accident work-related?
Do you receive either of the following;
Income Information
For the following section, please list the amount of income, before taxes, earned by ALL PERSONS in the family unit. Include the following types of income: wages/salary/self-employment, child support/alimony, interest/dividends, disability benefits, retirement benefits, Social Security Income, Unemployment benefits, and any other type of income. Do not include income from loans.

Rows	Name of Person Receiving Income	Source of Income	How Often Received	Amount
1
2
3
4
5
6

If no income is received, how do you provide food and shelter for yourself/family?
If no income is received, how do you provide for other daily living expenses (i.e., help with bills, medications, etc.) for yourself/family?
Please check which types of proof of income that can be provided to GoochlandCares to verify income.
You may upload proof of income at this time OR may provide paper copies at your screening.

Browse Files
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I, {fullName}, certify that the information herein is an accurate to the best of my knowledge. I understand that the information is subject to verification. I understand that if my financial situation changes or I obtain health insurance, my eligibility status will need to be re-evaluated. I understand it is my responsibility to notify THE CLINIC of any changes in my financial situation. I authorize the release of my financial records (including Social Security Number) to RX Partnership, pharmaceutical companies and Access Now and/or their agents to determine my eligibility for financial assistance for medicines and verification during routine audits. This review is a check on eligibility only. It is not a guarantee that I will receive benefits from any source, and THE CLINIC offers no such guarantees. I understand that falsification of information submitted will jeopardize my consideration for the program.

I understand that once a client record is created, GoochlandCares may be required to retain certain information to comply with federal, state, contractual, audit, insurance, safeguarding, or operational requirements. Requests for deletion of information will be reviewed in accordance with organizational policy and applicable law.
Signature of Client [to sign you may use your mouse, track pad or finger on touchscreen]

To sign this form you may use your mouse, track pad or finger on touchscreen.
Submission Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Should be Empty: