FHASES
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Patient Application
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By completing and submitting this electronic form, I give consent for myself or a representative to submit information on my behalf. I certify that the information submitted is true to the best of my knowledge. I understand that submission of this from does not qualify me for KAPA and eligibility must be evaluated and will be confirmed with the applicant.
Once form has been submitted, please allow 24-48 business hours for KAPA to reach out and begin intake process.
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Ethnicity
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Latino Identity
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Preferred Language
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Housing Type
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Household Size
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Household Income (total annual)
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Marital Status
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Residency Date
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Health Insurance
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Citizenship Status
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Do you file taxes?
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version
v2024Q4.1.1
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