Fillable Enrollment Form - First Steps printable pdf download

Enrollment Form - First Steps

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FIRST STEPS ENROLLMENT FORM

PATIENT INFORMATION:

LAST NAME: _________________________________

FERTILITY CLINIC EMAIL (OPTIONAL) _________________

FIRST NAME: _________________________________

PHARMACY EMAIL (OPTIONAL): ____________________

PHONE NUMBER: ________________________________

STREET ADDRESS: _____________________________

CITY, STATE AND ZIP CODE: ______________________

GENDER:

Male

Female

DOB: _______________________________________

YOUR EMAIL ADDRESS:____________________________

TREATMENT

Physician Name: _______________________________________

Are you currently undergoing a treatment cycle using donor eggs?

Yes

If yes please provide Donor alias name

Donor Name ____________ Donor DOB ________

( If you don’t know your Donor’s alias name or DOB please ask your IVF center )

WE WILL NEED YOUR ANNUAL ADJUSTED GROSS INCOME FOR YOUR HOUSEHOLD.

These are the only acceptable documents the First Step Program uses.

• 1040 A

• 1040 MARRIED FILING SEPARATE

(Need Both)

• 1040 EZ

• 1040

st two pages showing lines 37 & 38 **

** YOUR SOCIAL SECURITY NUMBER IS NOT NEEDED PLEASE FEEL FREE TO BLOCK THAT OUT ON YOUR 1040**

the greater of the two will be honored.

ACCEPTABLE DOCUMENTS NEEDED FOR THE MILITARY DISCOUNT ARE:

• DD214

• LES (Leave and Earnings Statement)

• CAC or Uniformed Service ID Card

PLEASE SUBMIT YOUR ENROLLMENT FORM AND INCOME VERIFICATION TO ONE OF THE FOLLOWING:

MAILING ADDRESS:

2181 E. AURORA RD STE. 201

FAX: 855-672-9262

TWINSBURG, OHIO 44087

PATIENT SIGNATURE____________________________________

DATE _____ /_____ /_____

Enrollment Form - First Steps

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