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Tuesday, July 27, 2021
Pierce County Project Access Enrollment Application
First Name:
Middle Name:
Last Name:
Birth Date (MM/DD/YYYY):
Gender:
Female
Male
Street Address 1:
Street Address 2:
City:
Zip:
Mobile Phone:
Home Phone:
Work Phone:
Email:
Patient Income
Month
Year
Spouse\Other Income
Month
Year
Family Size
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Lived In County For:
yrs
mos
Medical Need:
Marital Status
Not answered
Single
Married
Widowed
Divorced
Separated
Parent-Head of Household
Do you file taxes? (Premium Assistance Program Only):
Yes
No
Are you eligible for any other health insurance options?:
Yes
No
Enter Text From Image (case sensitive):
Enter the code shown above:
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