Palco Enrollment Form English Project Access Lancaster County
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4Lancaster County Medical Foundation
Date: _____________________
Project Access Lancaster County
PALCO
480 New Holland Ave., Ste 8202
Lancaster, PA 17602
Phone: 717-392-1595
FAX: 717-735-9586
ENROLLMENT APPLICATION
Please complete a separate application for each person applying
Last Name, First MI
Social Security Number
Address
City
State
Zip Code
Home Phone
Work Phone
Cell Phone
Date of Birth
Emergency Contact Name and Phone
1. Referred by __________________________________________________________________________________
2. Are you applying for or receiving Supplemental Security Income (SSI)?
_____ Yes _____No
3. Do you have Medical Assistance through the Welfare Office?
_____ Yes _____No
If no, did you have Medical Assistance in the last 6 months?
_____ Yes _____No
If yes, reason for termination ____________________________________________________________________
4. Do you have a Medical Assistance application pending?
_____ Yes _____No
If yes, what date did you submit the application? ___________________________________________________
5. Do you have any other type of health insurance?
_____ Yes _____No
6. Do you have Medicare through Social Security?
_____ Yes _____No
7. Are you a veteran? _____ Yes _____No
If yes, do you receive Veterans’ Benefits?
_____ Yes _____No
8. Are you a spouse or widow of veteran?
_____ Yes _____No
If yes, do you receive Veterans’ Benefits?
_____ Yes _____No
9. What is your citizen status?
U.S. Citizen_____ Permanent Alien _____ Temp. Alien_____ Refugee/Asylee ____ Other______
10. Do you have a medical problem that keeps you from getting or keeping a job?
_____ Yes _____No
11. Are you applying for or receiving Social Security Disability?
_____ Yes _____No
If you are receiving Social Security Disability, what is the date your benefits began? _____________________
12. What is your monthly gross income from all sources? $___________
13. What is your family size ___________
14. What is your marital Status? Married_____ Single _____ Widow/Widower_____ Divorced_____ Other______
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