Alzheimer`s Identification Card Application

Alzheimer’s Identification Card Application
Neuroscience Centers of Florida Foundation, Inc. (NSCFF) offers a medical ID card to those affected by Alzheimer’s. This
card will serve to identify you or your loved one as an Alzheimer’s patient and will include doctor’s phone number and
emergency contact information. In order to receive the ID card, verification of the Alzheimer’s diagnosis is required,
along with a completed application and a $10 processing fee. You may have your physician sign a statement of your
diagnosis on official letterhead or a prescription pad. Physician verification can be faxed or mailed.
Please print and complete all information requested below:
Patient Name (as it appears on Driver’s License/Other Official Identification )
Address
E-Mail
Phone #
City
State
Doctor’s Name
Doctor’s Phone #
Emergency Contact Name
Emergency Contact Phone #
Zip Code
Please mail completed form, $10* for processing fees, and your physician’s verification (if not faxed) to:
Neuroscience Centers of Florida Foundation, Inc.
2150 Coral Way, 8th Floor
Miami, FL 33145
Phone: 305-856-8940; Fax: 305-456-3797
*Checks can be made out to Neuroscience Centers of Florida Foundation, Inc.
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