Medicaid Intake Form
Patient's Full Name
*
First Name
Last Name
Patient's Date of Birth
*
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Month
-
Day
Year
Date
Medicaid Number
Upload a picture of the child's current Medicaid card:
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I authorize We Are Better Together, LLC to bill Medicaid on my child's behalf.
Parent/Guardian's Printed Name:
*
First Name
Last Name
Today's Date
*
-
Month
-
Day
Year
Date
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