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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.