MHAP Patient Form MHAP Patient FormBasic InformationAre you filling this form on behalf of an individual Yes NoSuffixFirst NameLast NameGender Male Female Do not wish to discloseDate of BirthPrimary Phone Home Mobile WorkPhone NoEmailAddressAddress Line 1Address Line 2CityStateZip CodeMarital StatusDemographicsRacePreferred PronounPrimary LanguageEmergency ContactRelationship to ContactFirst NameLast NamePrimary Phone Home Mobile WorkPhone NoEmailAddressAddress Line 1Address Line 2CityStateZip CodeRequirementsUpload the front picture of your valid idChoose File Upload the back picture of your valid idChoose File Lease agreementChoose File Current utility billChoose File Mail postmarked (last 30 days)Choose File Driver’s licenseChoose File PassportChoose File Insurance IDChoose File Birth certificateChoose File Legal permanent Resident CardChoose File Legal guardianship papersChoose File Pay StubChoose File Bank statementsChoose File Employer statement (Letter)Choose File Tax Returns (1040)Choose File Disability Insurance DocumentationChoose File Social Security paymentsChoose File Medicare IDChoose File Medicaid IDChoose File Commercial insurance IDChoose File Marriage certificatesChoose File Federal Tax returnsChoose File Other verifiable sources of proof of household size will be consideredChoose File Submit Form