Caring Partners Screening for Medicaid Benefits Form

Caring Partners of Morris/Sussex, Inc.
200 Valley Road Suite 406, Mount Arlington, NJ 07856
Phone: 973-770-5505 Fax: 973-770-5557

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Screening for Medicaid Benefits Form

Please complete this form in order to determine if the youth (you/your child(ren)) are eligible for NJ Medicaid and/or NJ FamilyCare benefits or that the youth enrolled in the CMO is eligible for Mental Health Only Medicaid (356000).

Caring Partners Staff Information
Please choose your Care Manager's name in the drop down below and then their name will appear in the "Care Manager Name Confirmation" box. Please click the button to complete the fields below in this section. If the Care Manager's name is not listed for some reason, please choose "*Not listed or unknown". If there is an error, you can skip the rest of this section.
Care Manager *
Care Manager Confirmation *
Staff Email
Click button above to fill in this field.
Extension
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Team
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Supervisor
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Sup Email
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Screening for Medicaid Benefits Form
Today's date *

Month Day Year
Name of Youth (as it appears on birth certificate): *

First Name Last Name
Youth CYBER ID: *
Please obtain this ID number from your Care Manager.
Date of Birth *

Month Day Year
Parent/Legal Guardian Name *

First Name Last Name
Relationship *

Parent Legal Guardian Self (Youth 18+)
By entering my email below, I will receive a signed copy of this authorization.
example@example.com
Is the youth currently receiving Medicaid benefits? *

Yes No
If yes, please provide policy# or social security# *