Enroll Form

Past Medical History

I DECLARE THAT I HAVE NO HEALTH INSURANCE COVERAGE FOR THE SERVICES BEING PROVIDED BY COMPASSIONATE CARE NETWORK, CCN.

I FURTHER DECLARE THAT MY BANK ACCOUNT AND COMBINED ASSETS INCLUDING PROPERTY, VEHICLES, CASH, AND JEWELRY ARE LESS THAN $5,000. MY ANNUAL INCOME IS NO MORE THAN $16,000. I ACKNOWLEDGE THAT ALL INFORMATION PROVIDED ABOVE IS ACCURATE TO THE BEST OF MY KNOWLEDGE.

ARE YOU ZAKAT ELIGIBLE

CHECK THIS BOX IF YOU AGREE THAT ALL STATEMENTS ARE TRUE, AND THAT YOU ACKNOWLEDGE THAT YOU ARE THE PERSON FOR WHOM THIS FORM IS FILLED OUT.

I DECLARE THAT I HAVE NO HEALTH INSURANCE COVERAGE FOR THE SERVICES BEING PRIVIDED BY CCN. I DECLARE THAT MY ANNUAL INCOME IS BELOW THE 400% FEDRAL POVERTY GUIDELINE THRESHOLD. I ACKNOWLEDGE THAT ALL INFORMATION PROVIDED ABOVE IS ACCURATE TO THE BEST OF MY KNOWLEDGE. I AGREE TO PAY THE FEE OF $25.00 FOR EACH OFFICE VISIT TO THE CCN PHYSICIAN ASSIGNED TO ME. I ALSO UNDERSTAND THAT LAB AND X-RAY CHARGES WILL BE ADDITIONAL AND WILL BE PAYABLE BY ME TO THE PHYSICIAN'S OFFICE OR TO THE FACILITY DIRECTLY. IF I NEED SPECIALIST CONSULTATION AND SUCH A CONSULTANT IS NOT AVAILABLE WITHIN CCN THEN I WILL SEEK A CONSULTANT OUTSIDE THE NETWORK AND WILL BE WILLING TO PAY THE CONSULTANTS REGULAR FEE. IN CASE OF A MEDICAL EMERGENCY, I AGREE TO SEEK EMERGENCY ROOM CARE AT THE NEAREST HOSPITAL FACILITY AND WILL NOT HOLD ANY CCN PHYSICIAN LIABLE FOR MY CARE. I UNDERSTAND THAT PREGNANCY CARE IS NOT INCLUDED IN MY MEMBERSHIP. I AGREE TO PAY THE MINIMUM MEMBERSHIP FEE OF $60.00 FOR SIX MONTHS (INDIVIDUAL) or $90.00 FOR SIX MONTHS (FAMILY), TO JOIN THE NETWORK UNLESS OTHERWISE WAIVED. I AGREE TO ENROLL FOR SIX MONTHS (INITIAL) AND TWELVE MONTHS (SUBSEQUENT RENEWALS). MAKE PAYMENT TO COMPASSIONATE CARE NETWORK. MAILING ADDRESS: 6348 N. MILWAUKEE AVE., #215, CHICAGO, IL 60646.

want to contribute

donate now

need more information?

Contact Us

Enroll Form

Past Medical History

Select Payment Method

Offline Payment Information

Select Enroll Type