MATClinics' Maryland Medicaid Questionnaire
Only fill this form out if you are enrolled in a Maryland Medicaid insurance program. Your card will have one of the following on it: Amerigroup Community Care, Aetna Better Health, Jai Medical Systems, Kaiser Permanente, Maryland Physicians Care, MedStar Family Choice, Priority Partners, University of Maryland Health Partners, United Health Care.

Maryland Medicaid requires providers to submit information about their patients in order to continue treatment. MATClinics accepts Maryland Medicaid and we need to make sure we have all the information necessary to fulfill Medicaid requirements. We need your help to make sure that there is no interruption in your treatment.

Much of this information is similar to what we ask in the intake form as well as at your appointments. Unfortunately we have no choice but to ask it again here, and then again every six months. Please take your time and be as accurate and careful as possible.

At the end there will be a SUBMIT button. Please do not leave this form until you have hit SUBMIT.

Thank you!

Email address *
Patient Name *
Your answer
Maryland Medicaid Number (11 digits and ends in two 00s) *
Your answer
Social Security Number *
Your answer
Date of Birth *
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Phone Number Privacy
By providing my mobile and/or home number (including any phone number that I later convert to a mobile phone number) through this form or otherwise, I consent to receive informational calls, text messages (including by auto dialers and/or with pre-recorded messages) by or on behalf of MATClinics regarding the processing of my request and for other transactional purposes. I understand that my consent for non-marketing, informational calls and messages applies to each phone number that I voluntarily provide to MATClinics now or in the future.
Phone Number *
Your answer
Next
Never submit passwords through Google Forms.
This form was created inside of MATClinics. Report Abuse - Terms of Service