If uninsured, list ID # for one of the ID types below (pick one)
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ID#
Your answer
Family/Support Information
Emergency Contact
Your answer
Relationship
Your answer
Phone Number
Your answer
Race/ Ethnicity
Check the box that best describes your race and Ethnicity
Race *
Ethnicity *
Housing Status
Check any box that describes your current housing situation
Do you live in a group setting like an Adult Foster Care or senior community?
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Consent *
Required
• Receiving testing and/or services by Cherry Health • Cherry Health ordering labs/testing • Billing insurance for care provided • Communicating results of testing with your employer for all employer required tests • Communicating test results to shelter / housing coordinators if accessing group living