Medicaid Eligibility Quick Questionnaire TAKE QUESTIONNAIRE Step 1 of 3 33% Who will you be applying for?(Required) Myself My partner A family member Someone else I help care for What is the age group of the individual?(Required) Under 19 19-64 65 or older What is the individual's current marital status?(Required) Single Divorced Widowed Separated, but not divorced What is the individual's current living situation?(Required) Living in a home or apartment Living with family or friends Assisted living Living in a nursing home Is the individual currently living in New York?(Required) Yes No Does the individual need support with daily living activities?(Required) Yes, regularly Sometimes or occasionally No Is the individual certified as blind or disabled, or do you have a disability that limits your ability to work?(Required) Yes No What is the individual's approximate monthly income from all sources (before taxes)?(Required) Less than $1,700 $1,700–$3,000 More than $3,000 Not sure Does the individual have savings, property, or other assets?(Required) Yes, under $30,000 Yes, over $30,000 No Not sure Does the individual currently receive Supplemental Security Income (SSI)? Yes No Does the individual currently have health insurance?(Required) Yes, Medicare Yes, employer-sponsored insurance Yes, private insurance No Name(Required) First Last Phone(Required)Email(Required) When is best to contact you? Morning Afternoon Evening
