SNAP Intake Form

SNAP Intake Form

* denotes a required field.

Facility Information
Facility Name *
Facility Address
Administrator *
Administrator E-mail *
Business Office Address *
Business Office E-mail
Telephone Number *
Fax Number

Applicant Information

Name *

Date Admitted

(please use mm/dd/yyyy format)

Gender *

Male Female

Marital Status *

Single Married Divorced Widowed

Date of Birth

(please use mm/dd/yyyy format)

Is the applicant competent to assist?

Yes No

Estimated Medicaid Start Date Needed

(please use mm/dd/yyyy format)

Additional Contact
Information

Name

Phone

Responsible Party

Name *

Relationship
to Applicant *

Address *

Phone Number 1*

Phone Number 2

E-mail*

Is there a Power of Attorney or Guardian?

Yes

If Yes: Name

Phone Number

Person Filing Form
If different than the above Responsible Party information, please fill out the fields below.

Name *

Address

Phone Number 1*

Phone Number 2

E-mail

Confirm E-mail

Prior Application Information

Has a Medicaid (MassHealth) application been filed previously?

Yes

If yes:

When

Where

Status of prior application?

Have Medicare benefits exhausted?

Yes

Exhaust date (if known)

(please use mm/dd/yyyy format)

Note: Please specify any difficulties the patient has that we should be aware of.

Payment: Please Check the appropriate box*

The FAMILY has agreed to pay PV Kent & Associates the $850 processing fee for the application.
The FACILITY has agreed to pay PV Kent & Associates the $850 processing fee for the application.