C4CPR PATIENT ASSISTANCE PROGRAM APPLICATION
** PRESS CTRL-P TO PRINT THIS APPLICATION ** Applications without copies of the following documents will not be processed: Proof of income (sliding scale based on total household income); rent or mortgage receipt; copy of Quest card (when applicable); copy of drivers license; copy of red-card (when applicable). Please do not send medical records. We will not return any documents, so please do not send originals. Extra postage will be required when return mailing.
Office hours are Monday through Thursday, 3-8 p.m. Please leave a message and we will get back to you within the week. We will make two attempts to reach a patient. If the patient doesn't answer or doesn't have voicemail set up, it will be up to the patient to contact us again. All applications without proper postage will be returned unopened to the sender.
Legal Name_________________________________ Date: ___________________
Physical Address: ______________________________________________________
Mailing Address (if different from physical address): _____________________________________________________
Email Address:__________________________
Valid Colorado DL.# or valid Colorado photo ID#: ______________________________
Date of Birth: ___________________
Telephone Number, Message number: ________________________ , _________________________
Primary care physician: (Please include full contact information.) ______________________________________________________________________________________________________
Specialty physician(s): (Please include full contact information. Please use back of sheet for additional information.)
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Diagnosis and prognosis: (Please use back of sheet for additional information) ______________________________________________________________________________________________________
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Medication Dosage Frequency Reason ______ How long have you taken it?
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(Please use back of sheet for additional information)
Do you receive Medicare or Medicaid benefits? Yes ____ Amount: _______ No ____
Do you receive SSI or SSD benefits? Yes ____ Amount: _______ No ____
Do you receive any other form of Workman’s Compensation or disability benefits? Yes ____ Amount: _______ No ____
Do you receive any form of public assistance such as TANF, LEAP, Food Stamps, WIC?
Yes ____ Amount: _______ No ____
Do you receive child support or alimony? Yes ____ Amount: _______ No ____
Are you currently employed, or receiving retirement or pension benefits?
Yes ____ No___
Net monthly income: _______ No ____
Do you receive unemployment assistance? Yes ____ Amount: _______ No ____
Total monthly household income: _______________ Number of people in household: __________
*If you receive any of these benefits or wages, please provide copies of documentation to this effect.
*For proof of residency, please provide a copy of your mortgage or rent bill*
*For identity verification purposes, please include a copy of your drivers license and MMJ card (when applicable)
*Incomplete applications will not be processed so to avoid delays, please ensure that you have provided all requested information with this application.
I declare and affirm that this information has been examined by me and to the best of my knowledge and belief, is in all things true and correct. I understand that the information I provide will be used to determine my eligibility for benefits. I understand that omitting or misrepresenting information may result in permanent disqualifications for any future benefits from Coloradans 4 Cannabis Patient Rights.
Client's Signature ____________________________________________
Date: _________________
If under the age of 18, Parent or legal guardian must sign here: __________________________________
Date: ______________
Parent or legal guardian please print name: ________________________________________________________________
C4CPR representative signature: _________________________________________________ Date: ________________
Print name: _______________________________________Date:_________________
Send completed application to:
C4CPR
Colorado Springs, CO 80933