HHHI / Bail Back Initiative Intake
Please complete this intake form to help us better support you. All information is confidential and used only for program eligibility and support.
HHHI / Bail Back Initiative Intake
Welcome. Please fill out the following information to the best of your ability.
Full Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Medicaid Status
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I have an Active Medicaid Card
I need to apply
I am uninsured
Medicaid ID #
NCID / State ID (Upload a clear image or PDF)
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Referral Source
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Court
Probation
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