Apply — SCN Program

Personal Information

First Name*

Last Name*

Date of Birth*

Medicaid CIN Number*

2 letters, 5 numbers, 1 letter. Example: AB12345C

Street Address*

Apt / Unit

Building Code

Floor Number

Building Directions

City*

State*

Zip Code*

Home Phone*

Format: (000) 000-0000

Cell Phone*

Format: (000) 000-0000

Email Address*

Select all that apply

Enrolled in Health Home Care ManagementSubstance Use Disorder diagnosisSerious Mental Illness diagnosisChild under 18 with a chronic conditionOther medical / mental health condition

Questions

Expecting / Is the eligible member pregnant?*

YesNo

Postpartum / Do you have a baby under the age of one?*

YesNo

Additional Household Members

Do you have additional household members?*

YesNo

By submitting, you confirm the information above is accurate and consent to being contacted regarding your application.

SCN Program Application

Personal Information

Questions

Additional Information

Additional Household Members