HCBS Waiver Eligibility Screening

Full Name

First NameLast Name

Date of Birth

Date

Phone Number

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

Email Address

example@example.com

Current Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Are you currently enrolled in Medicaid?

What is your primary disability or condition?

What is your current living situation?

Which daily activities do you need assistance with?

Estimated monthly income (before taxes)

Do you currently have a legal guardian or power of attorney?

Please provide any additional information that may help determine eligibility.

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