Retroactive Medicaid Application

Retroactive Medicaid Application
Apply for Medicaid coverage for previous medical expenses. Please provide all required information for your retroactive coverage request.
Full Name
First NameLast Name
Date of Birth
MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
List all household members (including yourself) who need retroactive Medicaid coverage
Which months are you applying for retroactive Medicaid coverage?
Other (please specify below)
If you selected 'Other', please specify the month(s) and year(s)
Total household monthly income before taxes
List any medical expenses incurred during the retroactive period
Do you or any household member currently have health insurance?
If yes, please provide the name of the insurance company and policy number (if available)
Signature of Applicant
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