Forms for patients and healthcare professionals

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

Forms Revised March 2016.

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 July 01, 2016 The Safety Net Foundation will only accept the current version of the Patient Application Form, released on April 01, 2016. Previous versions of the application received after this date will not be accepted.

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