• You First Logo

    You First Membership Application

    If you need help accessing or understanding this information, contact YouFirst@vermont.gov or (800) 508-2222.

    The You First program asks for personal information about race, ethnicity, education, gender identity, sexuality, disability, and language to ensure we are reaching all program-eligible Vermonters. Your answers are very helpful to our team in our work to reduce preventable differences in health outcomes, but you can choose the "prefer not to answer" response option.

    Section 1: About You

  • Date of Birth*
     / /
  • Do you have a Social Security Number?*
  • Pronouns*
  • Do you have an address?*
  • Format: (000) 000-0000.
  • Phone Type*
  • Is it okay to leave a message?*
  • How do you prefer to be contacted? (Select all that apply)*
  • Are you of Latino or Hispanic origin?*
  • What race or races do you identify with? (Select all that apply)*
  • What is your preferred language for written and verbal communication?*
  • Do you need us to call you with an interpreter?*
  • What is the highest level of education you have completed?*
  • Do you identify as an LGBTQ+ person (lesbian, gay, bisexual, transgender, queer)?
  • Do you have a physical, mental, learning, or emotional health condition or disability?*

  • You First Logo

    If you need help accessing or understanding this information, contact YouFirst@vermont.gov or (800) 508-2222.

    Section 2: Income

  • Income Frequency*

  • You First Logo

    If you need help accessing or understanding this information, contact YouFirst@vermont.gov or (800) 508-2222.

    Section 3: Health Insurance

  • Do you have health insurance?*
  • Coverage Start Date
     / /

  • You First Logo

    If you need help accessing or understanding this information, contact YouFirst@vermont.gov or (800) 508-2222.

    Section 4: Health History

  • Do you have, or have you had, breasts or a cervix?*
  • Do you have a primary care provider?*
  • Do you need help finding a doctor?*
  • Have you had a Pap or HPV test?*
  • Have you had a Mammogram?*
  • Do you have any cervical concerns or recent abnormal Pap or HPV tests?*
  • Do you have any breast changes, concerns, or a recent abnormal mammogram?*
  • Do you use any type of tobacco products (like cigarettes, cigars, or vaping products)?*
  • If yes, could we make a referral to 802Quits for you? 802Quits will contact you by phone and leave a message if they do not reach you.*
  • How did you find out about You First?*

  • You First Logo

    If you need help accessing or understanding this information, contact YouFirst@vermont.gov or (800) 508-2222.

    Section 5: Member Consent — Rights and Responsibilities

  • By signing this application, I am consenting to enroll in the You First program. I agree that I have completed the application with information that is true as far as I know. I authorize You First to access and share my health information.

    I authorize my doctor, clinic, hospital, laboratory, and lifestyle programs to share my information with the You First Program, so that they can make sure I receive quality care and so You First can pay my qualifying medical bills.

    I authorize You First to share personal health information about breast and cervical cancer screenings, heart disease risk factor screening, and diagnosis and treatment care with my doctor, nurse, hospital, clinics, and health care providers involved in my tests and treatment.

    You First is funded by the Centers for Disease Control and Prevention (CDC) which collects information from You First about how that funding is used. I authorize You First to share my deidentified information with the CDC. "Deidentified" means we will protect your privacy by hiding or removing information that would tell people who you are.

    I understand that when I enroll in the Vermont Department of Health’s You First program, I am giving permission for the program to share information about my eligibility with other Agency of Human Services (AHS) programs to coordinate services.

    My personal health information will be kept secure according to the Agency of Human Services (AHS) Privacy Practices and all applicable laws. I have received a copy of the AHS Notice of Privacy Practices.

    I understand that I have the right to withdraw from the You First program. If I no longer want to be enrolled in the program, I will send a letter or call You First so that I can be withdrawn. Please send a letter to: Vermont Department of Health, You First, Waterbury, VT 05671-8380 or call our Member Services Coordinator at 800-508-2222.

  • View and Download AHS Notice of Privacy Practices

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