Clearinghouse Application
|
Close Window
Prime Therapeutics State Government Solutions LLC
Prime Therapeutics State Government Solutions LLC
PATIENT INFORMATION
Patient Information
Applying for:
Self
Self And Spouse
Prefix:
Select Prefix
Mr.
Mrs.
Ms.
Miss
Legal First Name:
Middle Name:
Legal Last Name:
Suffix:
Select Suffix
Sr.
Jr.
II
III
IV
V
Residence Type:
Own/Rent
Live with Friend/Relative
Nursing Home
Patient Address:
City:
State:
Zip
Patient’s Phone #:
x
9999999999 x99999
Alternate Phone #:
x
9999999999 x99999
Your complete Social Security #:
Your Date of Birth:
(mm/dd/yyyy)
Gender :
Male
Female
Marital Status:
Single
Married
Other(Explain)
Prefix:
Select Prefix
Mr.
Mrs.
Ms.
Miss
Spouse’s Legal First Name:
Middle Name:
Spouse’s Legal Last Name:
Suffix:
Select Suffix
Sr.
Jr.
II
III
IV
V
Address Same as Patient:
Yes
No
Spouse’s Address:
Spouse’s City:
State:
Spouse’s Zip
Phone # Same as Patient:
Yes
No
Spouse’s Phone #:
x
9999999999 x99999
Spouse’s Alternate Phone #:
x
9999999999 x99999
Spouse’s Social Security #:
Spouse’s Date of Birth:
(mm/dd/yyyy)
Spouse’s Gender :
Male
Female
Number of residents in the household (dependent on your income):
How did you hear about the Clearinghouse?
Are you Power-of-Attorney for the above-named applicant(s)?
Yes
No
If YES, you will be required to provide a copy of the legal POA document.
When you have entered all the information, please click the “NEXT” button to advance to the next page.
NOTE :
Due to your living situation We need more information.
Please call us at 1-800-955-0989
.
Close