Screening application

Step 1 of 4

Personal information — Your name and contact details

Need help? Call us at 332-345-2010.

Do you have Medicaid? *

YesNo

Personal information

First name *

Last name *

Date of birth *

MM/DD/YYYY

Preferred spoken language *

Phone number *

Email address *

This program is only available to residents of New York.

Address type *

Street address *

Address line 2

Apartment, unit, or floor.

City *

State

New York only.

ZIP code *

If other people in your household may also qualify, you can add them here. This is optional — you can skip this section.

Your information is transmitted securely and reviewed only by authorized staff.