Eligibility screening

See if youqualify.

Fill out the form below and a team member will review your information. Required fields are marked with *.

We speak 12+ languages. Choose yours below and we'll call you in it.

Eligibility

These answers help us confirm whether this program may be a fit.

Do you have Medicaid? *

YesNo

Is the eligible member pregnant? *

YesNo

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

YesNo

Enter the eligible member's details as they appear on the insurance card.

Date of birth *

First name *

Last name *

Other household members on MedicaidAdd each household member enrolled in a regular Medicaid plan, exactly as on their insurance card.

Tell us where you live and how we can reach you.

Street address *

Apt / unit

City *

State *

ZIP code *5 digits

Email *

Primary phone *10-digit number. Your cell, if possible.

Secondary phone10-digit number.

Can your primary phone receive text messages, and do you agree to them? *

YesNo

Preferred language *The language you'd like your screening in.

Tell us about the food support and related benefits you may need.

Which food support would you like? *Switching later needs reauthorization and may cause a short gap in service.

Ready-prepared mealsRaw grocery items (I cook my own)

Allergies or dietary restrictions

Share anything else that can help our team follow up.

Have you received these services before?

YesNo

How did you hear about this program?

Anything else you'd like us to know?