MEDICAID INTAKE FORM

MEDICAID INTAKE FORM
Applicant Full Legal Name
Date of Birth

MonthDayYear
Date
Primary Residence Address
City
State
Zip Code
County
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Is the applicant a minor, under a guardianship or subject to a power of attorney?

If so, please provide the name and contact information for the applicant's legal guardian and/or POA and include a copy of the relevant legal documentation with this application
Upload guardian documentation (if applicable):

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Guardians name
Guardians email address
example@example.com
Guardian's phone number
Format: (000) 000-0000.
Referred By Agency/Individual
Referral Contact Information if applicable
ELIGIBILITY SCREENING
1) Is the applicant currently enrolled in Medicaid?
Medicaid CIN Number
2) Does the applicant have a disability that substantially limits one or more major life activities?
3) Household Composition & Total Household Income

Eligibility is based on TOTAL household income. Include all household members.
Number of people living in the household including applicant

Rows	Name	Relationship to Applicant	Date of Birth	Monthly Income	Income Source
1)
2)
3)
4)

Total Monthly Household Income
Total Annual Household Income
4) Housing Information
Does the applicant:
Type of Residence (check one):
(If renting) Owner Name
Owner Phone Number
Format: (000) 000-0000.
Owner Email Address
example@example.com
(Owner permission may be required prior to approval
6) Accessibility Modifications Requested
- Roll-in shower (wheelchair accessible)
- Walk-in tub
- Transfer shower w/shower seat
- Accessible toilet area
- Accessible lavatory
- Modifications to doors/entranceways
- Ramp
- Stairlift
- Flashing doorbell
- Accessible kitchen area
- Accessible laundry area
Accessibility modifications requested (also list if any other):
SUPPORTING DOCUMENTATION:

Required for ALL Applicants
Disability verification letter from medical provider

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State-issued ID for all household members age 18 or older

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Proof of household income for all household members (the most recent tax returns OR paystub OR confirmation of SSI/SSDI benefits received)

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Copy of Medicaid Benefit Card

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Sign this Notice of Privacy Practices and upload the same below (Right click, print, save as PDF)
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HOUSING DOCUMENTATION: if applicable
Current lease ( for renters)

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Deed including Schedule A (homeowners)

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Proof of current property taxes paid

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Proof of homeowner’s insurance

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Signature & Attestation: By signing I attest that all the information I have provided is true and accurate to the best of my knowledge.
If you have questions or need assistance completing this application, please contact BRIDGES at 845-624-1366.
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