Employee Landing

Are you the Patient?YesNo

Caller ID:Caller's Phone:Patient's Name

Important:

Do not enter anything other than single patients name. Leave blank and place info in note section if you're not sure.

Does Patient Reside in NY State?YesNoDoes Patient Have Medicaid?YesNoI don't know

Patient’s Medicaid number:

How to find Medicaid number?

The ID # is on the Medicaid Card under the "B".
Some people refer to card as Medicaid Card, Benefits Card, or Food Stamps Card. Use all 3 terms if caller is not sure what ID # we need.
The ID # is always in same Alphabetical-Numerical Sequence: 2 Letters, 5 Digits, 1 Letter. ex. YS12345W

Primary language:Notes:

CallRuby Intake Form