Contact Information:
Does the patient live in New York?*
Yes
No
Are you the patient?*
Yes
No
Does the patient have Medicaid?*
(Medicare is
NOT
enough)
Yes
No
I don't know
The patient needs Medicaid to join. (Medicare is NOT enough).
You need Medicaid to join. (Medicare is NOT enough).
Would you like help applying or determining eligibility?*
Yes
No
Patient will need Medicaid in order to join the program.
Unfortunately, this program is only for New York residents.
Description
*Marked fields are required fields.
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