Enrollee Application
This application is specifically for the person that is receiving services. It may be filled out by this person or their primary contact. An automatic email notification will be sent to the email address that you list below. Please double check to make sure that there are no typos, as this email will provide you with your next steps in the application process.
Email *
First & Last Name (of individual receiving services) *
Applying to receive: *
Waiver Type: *
County of Residence *
12 Digit Medicaid Number *
Social Security Number *
Date of Birth *
MM
/
DD
/
YYYY
Primary Phone Number *
Primary Email Address
Residency Type *
Primary Address (Street, City, State, Zip Code) *
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