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Service Inquiry Form
Fill out this form with the information and services you’re interested in, and an MCCAA representative will follow up within 48-72 hours. Participation is your choice. Your information is private and only shared with staff helping with your care.
This form is not an official application for MCCAA programs or services. All information requested is for the individual needing services. Additional information or documents may be needed to determine eligibility for specific programs. https://www.mercedcaa.org/services/
Note: If needing Utility Assistance/LIHEAP or Weatherization you must complete an application located under services on our website and supply the required documents listed on the application.
Name of Person needing Services
*
First Name
Last Name
Date of Birth (DOB) or Member ID Number
*
Note: We must either have a DOB or a Medical Member ID number in order to qualify for most services.
Email
*
example@example.com
Phone Number or best contact number
*
Please enter a valid phone number
Format: (000) 000-0000.
Best or Safest time to Contact
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Services you're interested in:
*
Early Learning
Housing + Shelter
Weatherization
Utility Assistance
Enhanced Care Management
Enhanced Care Management - Maternal Support Services
WIC (Women, Infants, and Children)
Diaper Bank Program
Additional Resources
Who is filling out this form?
*
Self
Authorized Representative of Individual needing services
Family or Friend on behalf of Individual needing services
Other
Additional information you would like to share with us
Please let us know what information or additional resources you're interested in.
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