Medicaid Screening

LITTLE TRAVERSE BAY BANDS OF ODAWA INDIANS

HEALTH DEPARTMENT

1260 AJIJAAK AVE

PETOSKEY, MI 49770

P: 231-242-1700

PRESCREEN FORM
For Medical Assistance Programs and Medicare Cost Sharing Programs

IMPORTANT NOTE:
This form and any necessary documents required to complete it will be subject to strict confidentiality and is only used to determine if you are eligible for medical assistance or cost-sharing programs.

This form is not an application for any benefits.

1st Adult Information

2nd Adult Information

First and Last Name: *

Date of birth: *

Social Security Number: *

Employer information (name, phone number): *

Employer information (name, phone #): *

Dependents under 18 years old

List each dependent's name and date of birth: