Medicaid Eligibility Interview Questionnaire

Medicaid Eligibility Interview Questionnaire
Use this questionnaire to gather information needed for a Medicaid eligibility interview. Please provide accurate household, residency, income, coverage, and contact details.
Applicant Information
Full name
First NameMiddle NameLast Name
Date of birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Preferred phone number
Please enter a valid phone number.Format: (000) 000-0000.
Email address
example@example.com
Household and Residency
Household Size
State of Residence
Does the applicant currently live in the state?
Eligibility Screening
Monthly household income
Current Medicaid coverage status
Special eligibility circumstances
Should be Empty: