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Medicaid Waiver Screening Form
Complete the Medicaid Waiver Services Screening Form to determine eligibility and connect with our team!
*
1.
What is your name? (First and Last Name)
(Required.)
2.
What is your email?
*
3.
What is your phone number?
(Required.)
*
4.
Do you live in Cortland County?
(Required.)
Yes
No
5.
Do you currently have active Medicaid?
Yes
No
Other (please specify)
6.
What type of support are you looking for? You can check all that apply.
Housing
Transportation
Nutrition/ Food
*
7.
Do you consent to a staff member from Access To Independence's 1115 program getting in contact with you regarding this request?
(Required.)
Yes
No
