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WELL-N-FIT
SLIDING SCALE & MEDICAID APPLICATION
Date
(Required)
Month
Day
Year
First name
(Required)
Last name
(Required)
Phone
(Required)
Email
(Required)
Birthday
(Required)
Month
Day
Year
Communication Preference
(Required)
Call
Text
Email
Video Chat
Contact Time Preference
(Required)
9am-10:30am
10:30am-3pm
3pm-6pm
6pm-9pm
Do you have Medicaid Health Insurance?
(Required)
Medicaid Insurance Company & Plan number
Medicaid ID Number
Medicaid Case Manager Name
Medical Case Manager Phone
For Medicaid Individuals choose your Community Oriented Recovery and Empowerment (CORE) service
Empowerment Services/Peer Support
Psychosocial Rehabilitation
Family Support & Training
Habilitation
Well-N-Fit Peer Advocacy Services
Mental Health
Professional Development
Physical Health
Recovery Support
How did you hear about EE Peer Advocacy Services?
Social Media
Community Event
Training/Workshop
Peer Advocate
Radio
TV
Submit
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