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Compassionate Care Network (CCN) : Application For

This document contains an application form for the Compassionate Care Network (CCN). It provides instructions to fill out the form and mail it with a $60 individual or $90 family payment for 6 months of membership. The form requests contact and health information to enroll individuals or family members. It details acknowledgements such as having no other health insurance and income below federal poverty guidelines. Fees of $25 for office visits and $35 for specialists are listed. Signing the form agrees to the terms of membership.

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Mir
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57 views1 page

Compassionate Care Network (CCN) : Application For

This document contains an application form for the Compassionate Care Network (CCN). It provides instructions to fill out the form and mail it with a $60 individual or $90 family payment for 6 months of membership. The form requests contact and health information to enroll individuals or family members. It details acknowledgements such as having no other health insurance and income below federal poverty guidelines. Fees of $25 for office visits and $35 for specialists are listed. Signing the form agrees to the terms of membership.

Uploaded by

Mir
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Fill out the form below and mail it with your payment of $60 for individual membership and

$90 for family membership for 6 months.


Please fill out a separate form for each family member you wish to enroll. You will receive an ID card for each form you send. Make
checks payable to: Compassionate Care Network , 6348 N. Milwaukee Ave., # 215, Chicago, IL 60646

APPLICATION FOR
COMPASSIONATE CARE NETWORK (CCN)
6348 N. Milwaukee Ave., # 215, Chicago, IL 60646
Tel (773) 775-3600 Fax (773)5831487; email [email protected]

NOTE: PLEASE PRINT YOUR INFORMATION ON THIS FORM IN CAPITAL LETTERS.

NAME___________________________________________________________________ DATE OF BIRTH_________________


Last Name First Name M.I

ADDRESS__________________________________________________________________________________________________

TELEPHONE_Home:______________________Work:_____________________ E MAIL_______________________________

SEX___M / F___AGE___________

HEALTH HISTORY
WHAT IS YOUR WEIGHT? ______________ WHAT IS YOUR HEIGHT? ______________

HAVE YOU HAD ANY PAST MEDICAL PROBLEMS?

Asthma ____ Cancer ____ Diabetes ____ High Blood Pressure ____ Heart Disease ____ Stroke ____

Any other Health Problem __________________________________________________________________________________

HAVE YOU HAD ANY SURGERY IN THE PAST No _____ Yes ______

IF YES DESCRIBE What _________________________________________________ When ___________________________

ARE YOU TAKING ANY MEDICATIONS? No ____ Yes____ If yes please list __________________________
___________________________
________________________________
DO YOU SMOKE? No ____ Yes ____If yes how much? ____________ ________________________________

DO YOU HAVE ANY OTHER HEALTH INSURANCE? Yes ___ No ___

Acknowledgements & Declarations: I declare that I have no health insurance coverage for the services being provided by CCN.
I declare that my annual income is below the 400% Federal Poverty Guideline threshold. I acknowledge that all information provided
above is accurate to the best of my knowledge. ,DJUHHWRSD\WKHIHHRIIRUHDFKRIILFHYLVLWWRWKH&&1SK\VLFLDQDVVLJQHGWRPHDQG
IRUWKH&&1VSHFLDOLVW,DJUHHWRSD\IRUHDFKRIILFHYLVLW. I also understand that lab and x-ray charges will be additional and will be
payable by me to the physician’s office or to the facility directly. If I need Specialist Consultation and such a consultant is not available within
CCN then I will seek a consultant outside the network and will be willing to pay the consultants regular fee. In case of a medical emergency,
I agree to seek emergency room care at the nearest hospital facility and will not hold any CCN physician liable for my care. I understand that
pregnancy care is not provided by CCN providers.I agree to pay the membership fee of $60 for individual membership and $90 for family
network.membership for 6 months, to join the enroll for six months (initial) and twelve months (subsequent renewals).
Payments are to be made to Compassionate Care Network and mailed to 6348 N. Milwaukee Ave., # 215, Chicago, IL 60646.

Applicant Signature _________________________________ Date Signed _____________________________

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