Free Medicaid Consultation Form

For whom are you considering applying for Medicaid? *

Where does the individual applying for Medicaid currently reside? *

What is the age of the individual applying for Medicaid? *

For what reason is the individual applying for Medicaid? *

Is the individual applying for Medicaid married or single? *

Is the individual a veteran or the widow / widower of a veteran? If so did they serve during war-time? *

What is the total monthly household income of the individual or couple applying for Medicaid? *

Does the individual applying for Medicaid own a home and if so what is the value of their home equity? *

What are the total financial assets of the individual or couple applying for Medicaid (not including their home)? *

How soon do you anticipate the need for Medicaid?

What benefits and / or coverage does the individual applying for Medicaid currently have? Check all that apply.