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Apply for Medical Assistance
Atomic Dev
2025-01-15T16:14:29-06:00
Apply For Medical Assistance
Looking for medical assistance? Complete the form below to apply and so we can help you access the care you need.
Fill out the form to apply:
Step
1
of
7
14%
I read the requirements, meet the initial requirements, and understand that just completing the application does not guarantee approval for assistance.
(Required)
Yes
Patient Information
Name
(Required)
First
Middle Name
Last Name
Sex (M/F):
(Required)
Select One
Male
Female
Language:
(Required)
Select One
Spanish
English
Other
Date of Birth:
(Required)
MM slash DD slash YYYY
Address
(Required)
Apt #
City
(Required)
Zip Code
(Required)
Select One
75001
75023
75115
75116
75204
75205
75209
75219
75220
75225
75229
75230
75231
75234
75235
75240
75243
75244
75247
75248
75251
75252
75254
75287
You must live in our service area. If not you can call 211.
Telephone # where you can be reached:
(Required)
Re-Enter Telephone # where you can be reached:
(Required)
Type of phone:
(Required)
Select One
Cell
Home
Consent to text:
(Required)
Select One
No
Yes
Can we leave detailed information on the phone listed above?:
(Required)
Select One
No
Yes
Email Address:
(Required)
Re-Enter Email Address:
(Required)
Race:
(Required)
Select One
Asian
American Indian
Black
Hispanic
White
Other
Ethnicity:
(Required)
Select One
Hispanic/Latino Spanish
Not Hispanic or Latino
Marital Status:
(Required)
Select One
Single
Married
Divorced
Widowed
Other
Total # of people living in household:
(Required)
Combined Monthly Income $
(Required)
Do you have insurance:
(Required)
Select One
No
Yes
Insurance Name:
(Required)
Do You Have Parkland Plan:
(Required)
Select One
No
Yes
Have you had immunizations here:
(Required)
Select One
No
Yes
Parent/Legal Guardian Name:
Emergency Contact:
(Required)
Select One
Spouse
Parent
Son/Daughter
Aunt/Uncle
Guardian
Grandparent
Brother/Sister
Friend
Other
Emergency Contact Name:
(Required)
Phone Number
Re-Enter Phone Number
Cell/Home:
(Required)
Select One
Cell
Home
Household Information
List Information regarding ALL OTHER ADULTS Age 18 or over living in your household:
DO NOT LIST YOURSELF BELOW - ANYONE ELSE LIVING AT RESIDENCE SHOULD BE LISTED
Total additional # of people living in household:
(Required)
Please enter a number greater than or equal to
0
.
Adult 1 First and Last Name
Adult 1 Sex: M/F
Adult 1 Male or Female
Select One
Male
Female
Adult 1 Date of Birth:
Relationship to You:
Adult 1 Relationship to You
Select One
Husband - Esposo
Wife - Esposa
Son - Hijo
Daughter - Hija
Brother - Hermano
Sister - Hermana
Father - padre
Mother - Madre
Grandfather - Abuelo
Grandmother - Abuela
Father-in-law - Suegro
Mother-in-law - Suegra
Grandson - Nieto
Granddaughter - Nieta
Son-in-law - Yerno
Daughter-in-law - Hijastra
Brother-in-law - Cunado
Sister-in-law - Cunada
Nephew - Sobrino
Niece - Sobrina
Uncle - Tio
Aunt - Tia
Cousin - Primo
Fiance - Prometido
Boyfriend - Novio
Girlfriend - Novia
Friend - Amigo
Unknown
Adult 1 Photo ID #
Adult 2 First and Last Name
Adult 2 Sex: M/F
Adult 2 Male or Female
Select One
Male
Female
Adult 2 Date of Birth:
Relationship to You:
Adult 2 Relationship to You
Select One
Husband - Esposo
Wife - Esposa
Son - Hijo
Daughter - Hija
Brother - Hermano
Sister - Hermana
Father - padre
Mother - Madre
Grandfather - Abuelo
Grandmother - Abuela
Father-in-law - Suegro
Mother-in-law - Suegra
Grandson - Nieto
Granddaughter - Nieta
Son-in-law - Yerno
Daughter-in-law - Hijastra
Brother-in-law - Cunado
Sister-in-law - Cunada
Nephew - Sobrino
Niece - Sobrina
Uncle - Tio
Aunt - Tia
Cousin - Primo
Fiance - Prometido
Boyfriend - Novio
Girlfriend - Novia
Friend - Amigo
Unknown
Adult 2 Photo ID #
Adult 3 First and Last Name
Adult 3 Sex: M/F
Adult 3 Male or Female
Select One
Male
Female
Adult 3 Date of Birth:
Relationship to You:
Adult 3 Relationship to You
Select One
Husband - Esposo
Wife - Esposa
Son - Hijo
Daughter - Hija
Brother - Hermano
Sister - Hermana
Father - padre
Mother - Madre
Grandfather - Abuelo
Grandmother - Abuela
Father-in-law - Suegro
Mother-in-law - Suegra
Grandson - Nieto
Granddaughter - Nieta
Son-in-law - Yerno
Daughter-in-law - Hijastra
Brother-in-law - Cunado
Sister-in-law - Cunada
Nephew - Sobrino
Niece - Sobrina
Uncle - Tio
Aunt - Tia
Cousin - Primo
Fiance - Prometido
Boyfriend - Novio
Girlfriend - Novia
Friend - Amigo
Unknown
Adult 3 Photo ID #
Adult 4 First and Last Name
Adult 4 Sex: M/F
Adult 4 Male or Female
Select One
Male
Female
Adult 4 Date of Birth:
Relationship to You:
Adult 4 Relationship to You
Select One
Husband - Esposo
Wife - Esposa
Son - Hijo
Daughter - Hija
Brother - Hermano
Sister - Hermana
Father - padre
Mother - Madre
Grandfather - Abuelo
Grandmother - Abuela
Father-in-law - Suegro
Mother-in-law - Suegra
Grandson - Nieto
Granddaughter - Nieta
Son-in-law - Yerno
Daughter-in-law - Hijastra
Brother-in-law - Cunado
Sister-in-law - Cunada
Nephew - Sobrino
Niece - Sobrina
Uncle - Tio
Aunt - Tia
Cousin - Primo
Fiance - Prometido
Boyfriend - Novio
Girlfriend - Novia
Friend - Amigo
Unknown
Adult 4 Photo ID #
List Information for ALL CHILDREN under 18 living in your household:
Total additional # of children living in household:
(Required)
Child 1 First and Last Name
Child 1 Sex M/F
Child 1 Date of Birth:
MM slash DD slash YYYY
Child 1 Relationship to You
Child 2 First and Last Name
Child 2 Sex M/F
Child 2 Date of Birth:
MM slash DD slash YYYY
Child 2 Relationship to You
Child 3 First and Last Name
Child 3 Sex M/F
Child 3 Date of Birth:
MM slash DD slash YYYY
Child 3 Relationship to You
Child 4 First and Last Name
Child 4 Sex M/F
Child 4 Date of Birth:
MM slash DD slash YYYY
Child 4 Relationship to You
Child 5 First and Last Name
Child 5 Sex M/F
Child 5 Date of Birth:
MM slash DD slash YYYY
Child 5 Relationship to You
Child 6 First and Last Name
Child 6 Sex M/F
Child 6 Date of Birth:
MM slash DD slash YYYY
Child 6 Relationship to You
Child 7 First and Last Name
Child 7 Sex M/F
Child 7 Date of Birth:
MM slash DD slash YYYY
Child 7 Relationship to You
How did you hear about our clinic:
(Required)
Select One
Church
Emergency Assistance
Food Pantry
Word of Mouth
Other
Reason for Visit?
(Required)
Medical Clinic requires photo id, proof of address, and previous vaccination records. You can upload documents no or bring them with you to your doctor visit.
Photo ID:
Accepted file types: jpg, jpeg, png, pdf, doc, Max. file size: 50 MB.
Proof of residency (ex. Utility Bill):
Accepted file types: jpg, jpeg, png, pdf, doc, , Max. file size: 50 MB.
Vaccination Records:
Accepted file types: jpg, jpeg, png, pdf, doc, Max. file size: 50 MB.
You will receive a call to schedule your appointment.
Comments
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