Forms for patients and healthcare professionals

To get started, the patient must complete and submit the Patient Application Form.

Forms Revised December 2015.

Once a completed application and any required supporting documents have been received and processed the patient and provider will be notified of the enrollment decision. Missing information or an incomplete application will delay an enrollment decision.

As of January 01, 2016 The Safety Net Foundation will only accept the current version of the Patient Application Form, released on December 18, 2015. If an older version of the application is submitted we will notify you to complete the current form and re-submit.

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