Application/Aplicación Choose Your Language / Elige tu idioma English Español For over 30 years, Access to Care (ATC) has helped low-income, uninsured, and under insured individuals living in suburban Cook County and northwest Chicago to access a primary care doctor in their community.You are about to apply online for membership in the Access to Care program. If you are currently an ATC member, you can also use this application to re-enroll. ATC members receive $5 co-pay primary doctor visits, $5 lab and x-ray tests, a prescription plan with affordable options of $15 to $40, and more! ATC welcomes all residents in our geographical area regardless of race, age, religion, country of origin, gender identity, sexual orientation, physical/mental ability, or immigration status. In the following application, you will be asked to confirm your eligibility for the ATC program which includes: 1) living in suburban Cook County or northwest Chicago; 2) a family income of under 300% of the Federal Poverty Guidelines; 3) no health insurance (or a deductible of $1,500 or more per person); and 4) ineligibility for programs such as Medicaid and Medicare If you are unsure about your eligibility, do still fill out the application. It is also fine if you do not have all the documents on hand to fully complete the application. Complete what you can online and ATC will contact you for any missing or incomplete information. There is typically an application enrollment fee of $20 to $50. However, during these difficult times, Access to Care is temporarily waiving ALL application enrollment fees so that we can help you and your family get access to a doctor. If you have any questions, please call us at 708-531-0680 (M-F; 9am to 5pm) or email us at email@example.com. As always, if you prefer to apply via paper copy/regular mail or in-person at an ATC Intake Site, click here.Do you live in any SUBURB of Cook County? Or live in northwest Chicago with the following zip codes: 60630; 60631; 60634; 60639; 60641; 60646; 60656; 60707?*YesNoThank you for your interest, however, you are not currently living in an Access to Care service area. We encourage you to explore one of these options: If you live in Cook County, you may be eligible for CountyCare—an Illinois Medicaid managed care health plan. You can visit www.countycare.com or call 312-864-8200. If you live in Chicago, call 312-744-5000 or visit 311.chicago.gov, for services available. If you live in DuPage County, contact Access DuPage, which connects low income and uninsured DuPage County Residents to affordable health services. Visit: www.accessdupage.org or call 630-510-8720. If you live in Will County, visit www.willcountyhealth.org or call 815-727-8670. If you live in Kane County, visit www.kanehealth.com or call 630-208-3801. Contact your local township office to learn what services are available to residents Email ATC at firstname.lastname@example.org and we will try to assist you Family InformationProvide information for the everyone in your family household who is applying for the Access to Care program.Start with yourself, then your spouse/partner, followed by any dependents. Your dependents, potentially eligible for Access to Care, must be ages 19-26 only. Children ages 0-18 are not eligible for Access to Care services. Use the + and - symbols to add or remove additional rows as needed.First Name [REQUIRED]Last Name [REQUIRED]Middle InitialGenderDate of Birth (MM/DD/YYYY) MF Indicate Family SizeTell us how many TOTAL family members are in your household. This means you, your spouse/partner, dependents ages 19-26, and children ages 0-18.If you would like to add any explanation or information about your household, add it here:Personal InformationAddress* Street Address [REQUIRED] Apt/Unit # City [REQUIRED] AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State [REQUIRED] ZIP [REQUIRED] Phone*Email Note: Access to Care will not sell your private information, but we will email you updates about the ATC program.Ethnicity American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White Other Ethnicity (other)Please provide your ethnicity:Primary LanguageEnglishSpanishAre you eligible for public aid?YesNoUnsureIf you are unsure, Access to Care staff will contact you to help.Do you have health insurance?YesNoIf yes, what is your deductible?Documentation UploadThe documents you are submitting will be kept confidential. They are used only by Access to Care staff to ensure you are in a community we serve and are not otherwise eligible for a more comprehensive health care program (eg, Medicaid). You can upload the documents from your laptop or use your mobile device to take and upload a photo of the documents. If you don’t have all the documents available right now, submit what you have and Access to Care staff will contact you about the additional documents. If you prefer to mail copies, send to: Access to Care, 2225 Enterprise Drive, Suite 2507; Westchester, IL 60154; Attention: Online Application As always, Access to Care welcomes all in our service area regardless of their race, religion, country of origin, gender identity or immigration status.Proof of Support or IncomePick what best describes you and each person in your family applying for the Access to Care program and upload the requested information for each: -No Income: If you live rent-free, upload a letter from the person you live with, noting you are living there rent-free -Employed: Upload your last two (2) paycheck stubs (you and/or spouse). Or upload a letter from your employer stating your employment and income. -Fixed Income: Upload proof of Social Security payments (for you and/or spouse). -Self-Employed: Upload your most recent federal income tax form (1040) and your most recent profit and loss statement (Schedule C). -Unemployed: Upload unemployment compensation statement for you and/or spouse. Drop files here or Proof of AddressFor example, upload 1 of the following to show you/your family’s address: -Drivers License -State ID -A bill: cell phone, cable, electric, etc. (make sure address is visible) -Lease or Mortgage (make sure address is visible) -Or other document showing your current address Drop files here or Proof of IdentityFor example, upload 1 of the following documents for each person applying for the Access to Care program: -Birth certificate -Social security card -Voters registration card -Passport -Naturalized citizen certificate -Permanent residency card -Visa -Designation of a refugee or politician asylum seeker -DACA ID -Or other document Drop files here or If you would like to add any explanation or additional information about the documents you have uploaded, add it here.How did you learn about Access to Care?Returning MemberFamilyFriendSocial mediaSigns/Flyers in the communityIf returning member, enter your previous membership number:ACCESS TO CARE AUTHORIZATION FORM*I hereby authorize the Suburban Primary Health Care Council (‘the Council’) to use any medical information, which we refer to as “Protected Health Information,” about me in the following two ways. --If I choose to see a contracted healthcare provider, then the Council may assist that contracted healthcare provider in making a referral to another healthcare provider to provide me with treatment. I understand that, for example, a contracted doctor who I choose to see may send Protected Health Information about me to the Council so that the Council can refer me to another healthcare provider for additional services that the doctor says I may need. I understand that the Council will not use Protected Health Information that it receives in this manner for any purpose other than to refer me to another healthcare provider for additional treatment; and --I understand that the contracted healthcare providers who I choose to see will send the bills for their services to the Council for payment. I further understand that these bills will contain Protected Health Information about me. By choosing to participate in the Access to Care Program, I authorize the Council to obtain Protected Health Information about me from contracted healthcare providers who I choose to see so that the Council can pay for my healthcare. I understand that the Council will not use Protected Health Information about me it receives for any other purpose than bill payment. This authorization is valid from the date that I chose to become a member of the Access to Care Program, and ends on the date on which I stop being a member of the Access to Care Program. I understand that I have the right to revoke this Authorization in writing by notifying the Council that I have revoked this Authorization, but I also understand that if I revoke this Authorization, I will lose the benefits covered by, and will no longer be eligible for, the Access to Care Program. I have had the opportunity to read this Authorization, and I understand what this Authorization means. I AgreeSUBURBAN PRIMARY HEALTH CARE COUNCIL ACCESS TO CARE PROGRAM*ENROLLEE ACKNOWLEDGMENT AND RELEASE RIGHT OF APPEAL/GRIEVANCE PROCEDURE: I understand that I may appeal any decision regarding my eligibility for the Program within 14 days of such decision by submitting in writing a grievance to the Suburban Primary Health Care Council. CIVIL RIGHTS: I understand that the Suburban Primary Health Care Council is an equal opportunity program open to all eligible persons regardless of age, race, sex, national origin, religion, disability, sexual orientation, or any other class of people protected by any federal, state or local law. If I believe I have been discriminated against I may submit, within 14 days of the event, a written grievance to the Council. DUAL PARTICIPATION: I have been informed that eligibility for he Medicaid Program, the Medicare Program, or receiving benefits under private health insurance for physician office visits may result in my termination from the Suburban Primary Health Care Council’s Access to Care Program (“Program”). I certify that as of this date I do not participate in the programs or receive the benefits described in the preceding sentence. I agree to inform promptly the Suburban Primary Health Care Council if I begin to participate in such programs or begin to receive such benefits. NON-TRANSFERABLE: I understand that enrollment is limited to the person (s) named on this application form and is not transferable. Giving my temporary or permanent identification as a Council client to any other person to use will result in my termination from the Program. LIMITATION OF SERVICES: I understand and acknowledge the following: --Services provided by physicians under this Program are limited to a specific set of routine basic health care services which exclude, among other services, the following: some procedures normally provided by primary care physicians, service provided in the emergency room of a hospital, ambulatory specialty care and inpatient services. --A Non-Refundable Annual Enrollment fee of $20.00 for one person, $40.00 for two people, or $50.00 for a family of three or more. Payment of the enrollment fee does not guarantee continued services for one year. --Physicians require payment by me of $5.00 per visit. --Pharmacies require payment by me of $15.00 per prescription for generic drugs, $30.00 per prescription for preferred brand name drugs and $40.00 per prescription for non-preferred brand name drugs. Prescriptions will be limited to a 30 day supply. --I must pay $5.00 for each lab and/or x-ray procedure. --Only certain physicians and pharmacies are participating in the Council Program and that for a variety of reasons certain physicians and pharmacies may leave the Program at any time. --That certain participating physicians may be unavailable because they do not have room for additional patients; (i) my physician may request that I be transferred to another physician and under certain circumstances the Council will grant such a request; (ii) if I or my physician request my transfer to another physician, it may take up to 60 days to provide me with a new physician; and (iii) my physician will not be available at all times and may refer me to another physician who is participating in the Program. --My participation in the Program will expire on the date of my Access to Care card unless I meet the eligibility standards for the Program at that time and renew my participation in the Program. The Council has no obligation to advise me further of the date on which my participation in the program will end or to initiate renewal of my participation. My participation in the Program my be terminated at any time that I am no longer eligible for the Program, as the Council may establish general standards for eligibility from time to time. --Changes in program expenses or funding may require modification or termination of the Program at any time; therefore, access to program services even during my enrollment period are not guaranteed. HOLD HARMLESS: I acknowledge that neither physicians participating in the program, nor any physician, clinic or hospital to which I may be referred, are employees, agents or partners of the Council and that the Council is not responsible to me in any way for the amount or quality of medical health care services which I may receive from a participating physician. I agree to hold harmless and release the Suburban Primary Health Care Council and its Directors, officers, employees, and agents from any liability arising from its arranging or attempting to arrange medical services for me through any healthcare provider or its payment of medical services on my behalf. RELEASE OF INFORMATION: I consent to the release of any and all medical, social, and financial information, as well as, the release of any and all information concerning eligibility for health insurance for myself and/or my dependents to the Suburban Primary Health Care Council, its agents, contractors, and service providers with whom it maintains a relationship. I authorize the Social Security Administration to release any information concerning my eligibility for Medicare and Social Security benefits. I understand that the release of any medical information about me by the Suburban Primary Health Care Council is limited by the authorization form, a copy of which is attached to this Enrollee Acknowledgment and Release. I understand that I cannot become an enrollee of the Program until I sign this form and the authorization form attached. I AgreeYour Name*Spouse NameYour Signature*Use your mouse to sign if on a computer. If on phone or tablet use your finger.Spouse SignatureUse your mouse to sign if on a computer. If on phone or tablet use your finger.Additional CommentsPlease add any additional comments you would like to share with the Access to Care staff.If you are an ATC Intake Site, please include your site number here.