MedWish MedWorks Navigation Contact Form
Our Navigators help answer your questions about health insurance and benefits while also providing community resource information. Please contact us to learn how we can help.
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First Name
Last Name
Date of Birth
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-
Month
-
Day
Year
Date
Which gender do you identify as?
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Male
Female
Non-Binary
Race/Ethnicity
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African American/Black
White/Caucasian
Hispanic/Latino
Native American/Pacific Islander
Two or more Races/Ethnicities
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
How can our Navigation team help you?
"I have questions about..." (please select all that apply)
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Medicaid
Medical
Vision
Medical Equipment
Marketplace Coverage
Medicare
Dental
Addiction
Mental Health
None of the above
Other
If "other", please explain.
"I need help with..." (please select all that apply)
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Health Insurance Enrollment (Medicaid)
Medical Supplies
Finding a provider (doctor, dentist, mental health counselor)
Food Assistance
Vision Care and/or Glasses
SNAP
How to use your insurance
None of the above
Do you have health insurance? Which plan are you enrolled with?
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Medicaid (Buckeye Health, CareSource, Molina, Paramount or United Healthcare)
Medicare
Other
I do not have health insurance
How did you hear about MedWish MedWorks?
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MedWish Medworks Website/Email
Social Media
Greater Cleveland Foodbank Flyer
Television ad/story
Email from another agency
Flyer from another agency
Family/Friends
Health Corners
Other
If "other", please specify.
Are you a caregiver?
*
Yes, to a child
Yes, to an adult
No
Is there anything else you would like us to know?
Submit
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