Glendale Area Medical Center

Please PRINT this form out and complete -- then bring it into the Medical Center when you arrive for your appointment!

Glendale Area Medical Center

P.O. Box 375

850 Main Street

Coalport, PA 16627

(814) 672-5141

ELIGIBILITY FORM

Name of Applicant ________________________________ Date____________

Address __________________________________ Telephone ______________

__________________________________

Patient's Name _____________________________ Birthdate ______________

Last date worked of principal wage earner ______________________________

(month/year)

Is spouse employed? ________

Total number in family residing with you ________ Please list below:

1. ___________________________ 5. ___________________________

2. ___________________________ 6. ___________________________

3. ___________________________ 7. ___________________________

4. ___________________________ 8. ___________________________

Type of medical insurance applicant or spouse now has __________________

MONTHLY INCOME

Earnings $_________________

Unemployment Comp _________________

Other _________________

Total _________________

I certify the above information to be true and correct to the best of my knowledge.

Signature of Applicant ____________________________________________