Call Screening

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Call Screening

Please fill out the below fields to request a Screener contact you to determine eligibility. We will contact people in the order in which they submit the screening. Please note that a screening takes about 20 minutes per household member..

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1
Name* This field is required.
First Name
Last Name
2
Birthday* This field is required.
Date
Month
Day
Year
3
Phone Number
Please enter a valid phone number.
4
What is the best days and times to call?
5
What insurance do you have?* This field is required.
Please Select
Fidelis Medicaid
Excellus Medicaid
United Healthcare Medicaid
6
Please list names and Date of Birth for all other household members. If you live alone, write N/A* This field is required.
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