Medicaid Expansion Waiver Application Form

Applicant Full Name

First NameLast Name

Date of Birth

Date

Gender

Non-binary/Other

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Residential Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Are you a U.S. citizen or legal resident?

Number of people in your household (including yourself)

Please list all household members (name, age, relationship to you)

Current health coverage status

Employment Status

Monthly household income (before taxes)

The last 4 digits of your Social Security Number (if applicable)

Applicant Signature