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Obtain Enrollment Forms |
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| Advocates: |
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To download enrollment forms, use the Login/Registration navigation link
to access the download function. An Advocate must register and use the assigned user ID
to access an enrollment form. The enrollment form can be completed online and printed, or
printed and completed at a later time. |
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Please click here
to access the Login/Registration page.
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| Patients: |
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The following three forms are required when visiting the Advocate to enroll in Bridges to
Access. |
| 1) Enrollment Signature Page |
| 2) Patient Health and Allergy Information Page |
| 3) Patient Enrollment Form |
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Please click here
to display the required forms. |
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| or call 1-866-PATIENT to receive by fax or mail. |
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Each enrollment form has a unique 9-digit identification number that serves as the patient’s Bridges to Access identification number for as long as the patient remains in the program. Each patient will need an original numbered enrollment form. Forms may not be photocopied.
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