Medicaid Disqualification Form

Medicaid Disqualification Form

This document is to make sure that you do not qualify for Medicaid. Filling out this application does not mean you will receive Medicaid nor are you applying for this government program. Medicaid approval can only be obtained through the appropriate government channels. Many of the questions on this form allow us to better assist you. This document is only for the use of this office.
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Answer these questions to see if you may be eligible for this benefit:
Do you have prescription insurance?*
Are you pregnant? *
Are you over 65?*
Are you a citizen or legal alien?*
Do you have a disability or a family member in your household have a disability.*
(If yes, then check all that apply.)

BlindParalysisHearing ImpairedHIV or AidsLimb LossOther
Are you blind or partially blind?*
Including you how many people live in your home?*
1. What is the age of any children for whom you are responsible? (Check all that apply.) Select all ages of any children that you are responsible for. EX: if you have a 3 year old child and a 6 year old child, select 3 and 6.

01234567891011121314151617
Does any of your children have a disability in which they receive Medicaid or Social Security Benefits for?*
What is your annual income?*
By signing this document, you verify the above statements are true and accurate.
Name*

First NameLast Name
Date*

MonthDayYear
Date
Signature

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Important: After you submit this form please return to our website at communityrx.com and complete the other required forms. Thank You.
Please verify that you are human*
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