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This enrollment process is used to complete an application for a medical eligibility determination for Intermediate Care Facility - Intellectual Disability and Nursing Home programs. For financial eligibility determination for Medicaid, please contact your local county office.

Complete the fields on each screen and select the Continue button to move forward to each page.

The contact person could be contacted to answer any questions regarding the information entered in this enrollment application.

* Indicates a required field.
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Enter date in mm/dd/yyyy format.
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This should be the information of the person filling this application out that may be contacted if there are any questions on this application.

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Enter 10-digit phone number, including Area Code using 999-999-9999 format.


Enter a valid email in myemail@domain.com or my.email@domain.net format.

Enter a valid email in myemail@domain.com or my.email@domain.net format.

This should be the patient's information. The social security number (SSN) of the patient will be needed in the future to check the application status.

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*Enter 9-digit social security number.