Accessia Health & CaringWays Eligibility Form

Accessia Health is thrilled to partner with CaringWays, the nation’s only HIPAA compliant and secure CareFunding platform for medical expenses. You are about to take your first step in creating your own CaringWays page to raise funds to support your own healthcare journey.   To learn more about CaringWays, click here.

To get started on your CaringWays page creation, we will need to collect some basic information to determine eligibility.

If you are an existing patient, please enter your Patient ID when filling out this form.

If you already have a portal account, you do not need to complete this form. Please login here. Once you are logged in, you will find a link to CaringWays on the homepage of the portal.

Accessia Health ID

Primary Diagnosis ----SELECT---- Acromegaly Acute Lymphoblastic Leukemia Alpha-1 Antitrypsin Deficiency Alzheimer's Amyotrophic Lateral Sclerosis Ankylosing Spondylitis Anxiety and Panic Disorders Asthma Attention Deficit Disorder Autoimmune Hemolytic Anemia B-Cell Lymphoma Basal and Squamous Cell Skin Cancer Beta Thalassemia Bipolar Disorder Breast Cancer Cardiomyopathy Cataracts Chronic Inflammatory Demyelinating Polyneuropathy Chronic Kidney Disease Chronic Myeloid Leukemia Chronic Obstructive Pulmonary Disease (COPD) Circadian Rhythm Disorders Colorectal Cancer Cystic Fibrosis Depressive Disorders Diabetes Diabetic Retinopathy Duchenne Muscular Dystrophy Epilepsy Esophageal Cancer Fabry Fibrodysplasia Ossificans Progressiva Fibromyalgia Gallbladder Cancer Gastric (Stomach) Cancer Gastrointestinal Stromal Tumors Gaucher Disease Glaucoma Guillain-Barré Syndrome (GBS) Gum Disease Heart Disease Heart Failure Hepatitis C Hereditary Angioedema Hereditary Angioneurotic Edema Human Immunodeficiency Virus Huntington's Disease Hurler Syndrome Hurler-Scheie Syndrome Hypoparathyroidism Idiopathic Pulmonary Fibrosis Immune thrombocytopenic purpura Inflammatory Bowel Disease Inherited or Acquired Factor Deficiencies Inherited Retinal Diseases (IRD) Insomnia Interstitial Lung Diseases Kidney Stones Lambert-Eaton Myasthenic Syndrome Liver Cancer Lupus Macular Degeneration Metachromatic Leukodystrophy (MLD) Mixed Connective Tissue Disease Mood Disorders MPS I MPS II MPS III MPS IV MPS VI MPS VII Multifocal Motor Neuropathy Multiple Myeloma Multiple Sclerosis Myasthenia Gravis Neuromyelitis Optica Disorder (NMO) Non-Small Cell Lung Cancer Obsessive Compulsive Disorder Pancreatic Cancer Parkinson's Disease Personality Disorders Plasminogen Deficiency Pompe Post-traumatic Stress Disorder Primary Immune Deficiency Progressive Familial Intrahepatic Cholestasis (PFIC) Prostate Cancer Pseudobulbar Affect (PBA) Psoriatic Arthritis Pulmonary Fibrosis Pulmonary Hypertension (PH) Rare and Chronic Condition with Oral Health Need Rheumatoid Arthritis (Adult & Juvenile) Scheie's syndrome Schizophrenia & Schizoaffective Disorder Scleroderma Severe Combined Immunodeficiency (SCID) Sickle Cell Disease Sjogren's Syndrome Spinal Muscular Atrophy (SMA) Stroke Substance Use Disorder Systemic Sclerosis-Associated Interstitial Lung Disease Thrombotic Thrombocytopenic Purpura (TTP) Tic Disorders TMJ Disorders Tooth Decay Urea Cycle Disorders

First Name

Last Name

Address 1

Address 2

City

State ----SELECT---- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Zip Code

Date Of Birth

Social Security Number

Gender ----SELECT---- Female Male Unspecified

Phone Number

Email Address

I verify that the information I have provided in this application is current, complete, and accurate.  Accessia Health may verify income and diagnosis through 3rd party vendors or other entities.

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