Apply for Medicaid

Medicare/Medicaid info

* Indicates required field

Have you recently applied for and been denied Medicaid in your current state? *

Medicare number ............ - 1EG4-TE5-MK72 *

(PART A) EFFECTIVE DATE *

(PART B) EFFECTIVE DATE *

Personal Information:

Name *

First

Last

Date of Birth (Example 01-01-2001) *

Phone Number *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

What county are you in *

What's your race *

Marital status *

Your Social Security Number (Optional) *

If spouse needs coverage, what's your his/her Social Security number *

Does anybody applying for coverage have Disabilities that affect your ability to work or attend school. *

Does anybody applying for coverage need help with bathing, dressing, or using the restroom *

Income Info:

Your monthly income (calculate the gross of all steams of income) *

Spouse's monthly income (calculate the gross of all steams of income) *

What's your income Source *

What's your spouse's income source *

If self-employed, what type of work *

Self-employed spouse, type of work *

Employer name (Self if self-employed) *

Spouse's employer name *

Employer's phone# *

Spouse's employer's phone# *

How much do you pay monthly for student loans *

How much does spouse pay monthly student loans *