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Member Enrollment: Request Information

Provide the initial enrollment and contact information to begin the member enrollment process.

1. Select an application type.
1. For Nursing Home application type only: Select an entry type. If the enrollment type is Evaluation or Transfer, then select Yes | No for the diagnostic question.
2. Enter an application date.
3. Enter contact last name and first name.
4. elect an applicant type.
5. Select a preferred communication method.
6. If email is the preferred communication method, enter the contact email and confirm email.
7. If phone is the preferred communication method, enter a contact phone.
8. Enter patient information including the first and last name, SSN and optionally the Medicaid #.

• Click Continue to move to the next step in the enrollment process.2
• Click Cancel to exit the enrollment process. The enrollment data will not be saved.