SECTION I - IDENTIFYING INFORMATION

Medicaid Gold Card Number *

Last Name *

First Name *

Telephone Number *

Social Security Number *

Apartment Number

Home Street Address *

City *

Type of Home Address

County *

Zip Code *

Mailing Address *

How may we contact you? *

Date of Birth *

Gender *

Your Current Age *

Total Monthly Income *

Your Race (Optional)

SECTION II - NEED DETERMINATION

Are you eligible for Medicaid Non-Emergency Transportation? *

Are you able to operate an automobile, even for short distances? *

Do you or anyone in your household own a car? *

What are your vehicle license plate(s) number(s)?

What is the total number of persons who reside in your household? *

Is this person related to you?

Enter the name of the person who resides with you.

Enter this person's Social Security Number

Does this person own a car?

If you live in an Assisted Care Living Facility, Nursing Home, ICFMR or Boarding Home, does this facility have a vehicle?

Have you ever been transported by the facility?

Do you have any family or friends who live in the County you reside in? *

Has this person(s) ever transported you to the doctor?

Would this person(s) take you to the doctor if you asked them?

Do you know someone who would transport you if you paid for the gas? *

SECTION III - DISABILITY

Can you walk without help to the following distances? (Check those that apply)

Are you currently receiving Supplemental Security Income (SSI)? *

Are you currently receiving Social Security Disability? *

Do you consider yourself to be disabled? *

If YES, what is the nature of your disability? (Check all that apply)

If you chose the disability type "Other" in the previous question, please describe.

SECTION IV - FREQUENCY OF USE/DESTINATIONS

What doctors or medical clinics do you visit on a regular basis? *