Forms & Documents

Application Forms

Application Instructions

Application

Signed Release Forms need to be returned with your application: English – Spanish (sign both front and back).

Intake/Registration Sites

What We Cover – English

What We Cover – Spanish

 

Member Forms

Once you are enrolled in Access to Care, you will receive “Your Guide to Access to Care” as well as information about pharmacy programs and services covered. Be sure to read the forms thoroughly.

Your Guide – English

Your Guide – Spanish

Medication Guide – English (July 2020)

Medication Guide – Spanish (July 2020)

Services Not Included – English

Services Not Included – Spanish

Lab Test Locations

X-ray Test Locations

ATC Flyer ‘What We Cover’ in additional languages:
Arabic
Farsi
Korean
Mandarin
Polish
Russian
Urdu