Access to Healthcare Network

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Please note: Completing the online application is the first step in the AHN enrollment process. You will be contacted by a Care Coordinator within 48 hours of receipt of the application; if you are not contacted by a Care Coordinator within 48 hours, please call us toll free at 1-877-385-2345.

If you are experiencing any difficulties with our online application. You may print a copy of the application and fax it to us at 775-284-8991 or call us for more information at 1-877-385-2345.

Today’s Date:

Employer Name:

Please answer all questions on the following pages, unless otherwise noted
If a question is not answered or is incomplete it may delay your application for AHN membership from being processed

Section A: Preliminary Eligibility Questions

Do you currently have health insurance?

Yes No

Have you dropped your employer sponsored health insurance within the last twelve months?

Yes No

Are you currently a Nevada resident?

Yes No

Section B: AHN Member Eligibility Information

Type of Application

A. Individual
B. Individual and Dependents
C. Dependents Only

Name

Date of Birth (DOB)

Gender

Last
First
Middle Initial

Male
Female

Physical Address

Address:

Apt.#

City:

Zip Code:

Office Use Only

Information Verified By AHN Staff

Yes No

Mailing Address
(If different than your resident address)

Address:		Apt.#
City:		State:
Zip Code:


7	Phone Number(s)	Home Phone:	( )
		Work Phone:	( )
		Cell Phone:	( )

Emergency Contact Information

Name:	Last		First
Relationship to You:
Phone Number:		( )

Family Income

Your Monthly Income

Your Spouses Monthly Income

Total Family Monthly Income

Office Use Only

Information Verified By AHN Staff

Yes No

Household Size

Dependents are defined as: individuals who live with you, are related to you, and that you support financially.
a	Type ‘1’ for yourself	b Type ‘1’ for your spouse ( ‘0’ if you are single)
c	Number of dependents aged 19 and younger
d	Number of dependents 20 to 24 years old
e	Number of dependents 25 to 64 years old
f	Number of dependents aged 65 and over
g	Add the numbers from parts a-f to get your household size. Household size

For Office use only

%FPL (determine by matching household income to household size on current FPL guidelines)

Section C: Family Member Information
If you are applying for an individual membership to AHN, skip ahead to section D.

Spouse

Name: Last:

First:

Date of Birth:

Dependents
(Age 19 and younger)

Name(s):

Last

First

DOB:

Last

First

DOB:

Last

First

DOB:

Last

First

DOB:

Dependents
(Age 20 to 23)

Name(s):

Last

First

DOB:

Last

First

DOB:

Last

First

DOB:

Last

First

DOB:

Dependents
(Age 24 and older)

Name(s):

Last

First

DOB:

Last

First

DOB:

Last

First

DOB:

Last

First

DOB:

Section D: Member Demographic Information


1	Primary Language
		English
		Spanish
		Other:


3	Marital Status
		Single or never married
		Married
		Unmarried Couple
		Separated or Divorced


4	Education
		Less than Ninth Grade
		Some High School
		High School Graduate or GED
		Some College
		College Graduate
		Other or No Response

2	Race and Ethnicity
		Asian or Pacific Islander
		Black or African American
		Hispanic or Mexican American
		Native American
		White or Caucasian
		Multi-Racial
		Other or No Response


5	Current Employment Status
		Employed full-time, one job
		Employed full-time, two jobs
		Employed part-time
		Temporarily Employed or Per Diem
		Unemployed and seeking employment
		Retired
		Student
		Other or No-Response

6	Length of Residency in Nevada
	If you have lived in Nevada for less than one year, fill in the number of months you have been here. If you have lived in Nevada for one year or more, fill in the number of years.
	Months Years

Section E: Health Care Historical Information
Your answers to the following questions will help us to better serve your health care needs. Answer to the best of your knowledge.

Recent Primary Care History

When was your most recent visit to a primary care physician? Include any visits to a medical clinic for non-emergency medical care.

One or more primary care visits in the past year

Between one and two years since my last primary care visit

More than two years since my last primary care visit

I have never had a primary care visit

Not sure

2	Emergency Room Use
		Your answer to this question is for informational purposes only and will not affect your application to become an AHN member.

How many times have you used the emergency room in the past twelve months?

In the following space please list the primary reason for the most recent visit: