All applications and authorization forms are available on our website.
The applications and forms are as follows:
- Application Form
- Authorization for Disclosure of Health Information Form
(This form must be completed by the applicant prior to consulting your doctor.)
- Diagnosis Verification Form
(This form must be completed by your Doctor.)
Information about the applications:
- Verification of residency in Jefferson County is required. An original phone, electric, sewer, water, rent or mortgage statement is accepted.
- All areas of each application must be completed except those marked JCOCC use Only.
- The more complete the information the quicker your application will be processed. All (3) forms and residency verification must be submitted to process your request.
- As applications are submitted, each will be given a case #, allowing as much confidentiality as possible. Only (1) Board Member will know the applicants name. We are dedicated to being fair with the hope of helping all that qualify for assistance.