Medical Assistance Application via Medicaid

These forms are easy to complete on-line and can save you time. You are able to save your application and go back to it at a later time to complete it or to make changes to your information. The e-forms eliminate the need for you to complete the same information on form after form by securely saving your information and automatically filling in similar fields on additional forms.

The forms are divided into steps to make it easier for you to complete. Each page has a button that can be clicked to go to the next question, back to the previous question, or to close the form. You can quit at any time by closing the form and the system will prompt you to cancel, save or print your data.

IMPORTANT: The system will time out after 30 minutes of inactivity. In order to save your application and be able to go back to it at a later time, you must Register or Login.

For information on eligibility or where to send your completed application, go to: www.med-quest.us/contactus.html. This information is also available on the last page of your printed application.

If you are experiencing technical difficulties with the form (i.e., not being able to save or print the form), please call toll free 866-457-7938 or go to the eForm FAQs page to view answers to frequently asked questions about these electronic forms (eForms).

IMPORTANT: Do not use the browser Back command to go to a previous page! This will result in the loss of the information you have entered.

Apply Now