Accessia Health - Dedicated Patient Champion

Patient Information

Relationship to Patient:

Patient First Name

Patient Middle Initial

Patient Last Name

Accessia Health is able to assist persons who are legally in the U.S. Please provide SSN, Alien ID, or Visa Number.

Social Security Number

Alien ID (A-******)

Visa Number

Date Of Birth*

Gender*

Marital Status*

Primary Language*

Can patient be claimed by a parent/guardian?

Are you of Hispanic, Latino, or of Spanish origin?

How would you describe yourself?

Race If Other, please specify

Address Information

Address Line 1*

Address Line 2

Zip Code*

City*

State*

Patient Contact Information

Primary Type*

Primary Phone Number*

Ext.

Please check if you would like to add a secondary phone number

Secondary Type

Secondary Phone Number

Ext.

Email Address

Communication Prefences

E-communications opt in: By checking this box you are agreeing to receive Accessia Health communications via email.This includes Privacy Practices updates, Accessia Health assistance related information and news.

Parent information for patients who are minors

Parent First Name*

Parent Last Name*

Parent Date of Birth*

Parent Address Information

Parent Street Address*

Address is the same as the Patient's.

Parent Street Address 2

Parent City*

Parent State*

Parent Postal Code*

Parent Contact Information

Parent Phone*

Phone is the same as the Patient's.

Parent Email Address

Email is the same as the Patient's.

Personal/Emergency Contacts

Please note, Accessia Health may only discuss the patient’s assistance with the patient or a personal authorized representative such as the patient's legal guardian or family member or friend. You may only authorize persons who can make healthcare or assistance decisions on the patient’s behalf.This is a legal requirement.

First Name

Last Name

Relationship to Patient

Phone Type

Phone Number

Ext

I authorize Accessia Health to discuss my information with this contact

Contact Email

Contact #2 (optional)

First Name

Last Name

Relationship

Phone Type

Phone Number

Ext

I authorize Accessia Health to discuss my information with this contact

Contact Email

Contact #3 (optional)

First Name

Last Name

Relationship

Phone Type

Phone Number

Ext

I authorize Accessia Health to discuss my information with this contact

Contact Email

Contact #4 (optional)

First Name

Last Name

Relationship

Phone Type

Phone Number

Ext

I authorize Accessia Health to discuss my information with this contact

Contact Email

Contact #5 (optional)

First Name

Last Name

Relationship

Phone Type

Phone Number

Ext

I authorize Accessia Health to discuss my information with this contact

Contact Email

Patient Information

Accessia Health is able to assist persons who are legally in the U.S. Please provide SSN, Alien ID, or Visa Number.

Can patient be claimed by a parent/guardian?

Are you of Hispanic, Latino, or of Spanish origin?

How would you describe yourself?

Address Information

Patient Contact Information

Communication Prefences

Privacy Practices

Assistance related Communication

Organizational Updates

Parent information for patients who are minors

Parent Address Information

Parent Contact Information

Personal/Emergency Contacts

Contact #2 (optional)

Contact #3 (optional)

Contact #4 (optional)

Contact #5 (optional)

Patient Information

Accessia Health is able to assist persons who are legally in the U.S. Please provide SSN, Alien ID, or Visa Number.

Can patient be claimed by a parent/guardian?

Are you of Hispanic, Latino, or of Spanish origin?

How would you describe yourself?

Address Information

Patient Contact Information

Communication Prefences

Privacy Practices

Assistance related Communication

Organizational Updates

Parent information for patients who are minors

Parent Address Information

Parent Contact Information

Personal/Emergency Contacts

Contact #2 (optional)

Contact #3 (optional)

Contact #4 (optional)

Contact #5 (optional)

Medicare Information