(We need one adult in the family to be the contact person for your application.)

1. First Name
2. Middle Initial
3. Last Name
4. Suffix
5. Address
6. Apt. / Suite
7. City
8. State Hawaii Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas US Virgin Islands Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
9. ZipEnter 5 digit zipcodeEnter 4 digits of zipcode suffixEnter 5 digit zipcodeEnter 4 digits of zipcode suffix-
10. County
11. Mailing Address, if different from home address
1. Address
2. Apt. / Suite
3. City
4. State Hawaii Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas US Virgin Islands Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
5. ZipEnter 5 digit zipcodeEnter 4 digits of zipcode suffixEnter 5 digit zipcodeEnter 4 digits of zipcode suffix-
6. County
12. Daytime Telephone Enter 3 digit area code of phone numberEnter first 3 digits of phone numberEnter last 4 digits of phone numberEnter phone number extension()- ext:
13. Other Phone Number Enter 3 digit area code of phone numberEnter first 3 digits of phone numberEnter last 4 digits of phone numberEnter phone number extension()- ext:
14. Info by Email

    Do you want to get information about this application by email?
    YesNo Email address
15. What is your preferred spoken language (if not English)?
16. What is your preferred written language (if not English)?
17. How many family members live with you?
18. Family Member Incarcerated

    Is any family member you usually live with incarcerated (detained or jailed) or residing in the Hawaii State Hospital?
    YesNo Please list their names
19. Parent living outside of home

    Does any child on this application have a parent living outside of the home?
    YesNo

    If yes, I understand I will be asked to cooperate with the Department of Human Services and the agency that collects medical support from an absent parent. If I think that cooperating to collect medical support will harm me or my children, I can tell Medicaid and I may not have to cooperate.