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African-American boy, shouting and jumpingI need more information

Important points about ARKids First and Medicaid
Who can get full Medicaid benefits?
What if you have Supplemental Security Income (SSI)?
Your Primary Care Physician (PCP)
What to do in an emergency
Your rights
Your responsibilities
Charges and bills
Using Medicaid with Medicare or other medical insurance
Medicaid and your new baby
Getting to the Doctor: NET (Non-Emergency Transportation)
Covered services
Important phone numbers
 

Use this form to request more information
about ARKids First.


First name
Last name
Mailing address
Address (continued)
City
State
Zip
County (Arkansas residents only)

(Please enter your telephone number
in the format 123-456-7890.)
Day telephone
Night telephone

Do you currently have a PCP provider?

Yes
No

If you do not have a PCP provider, in
which county do you receive medical care?

Please describe yourself.

Possible participant
Medicaid provider
Other

 
We collect age, race, and sex data for statistical purposes only. It is not used to determine eligibility, and you do not have to answer.

Your age:

Your race:
Black
White
Hispanic
Other

Your sex:
Male
Female


What do you have questions about?
(click all that apply)

Application question
Eligibility
Coverage
Other

Type any other questions in this box:


How would you like us to respond to
you? (click all that apply)

How did you hear about the ARKids First program?

 

Answer my question(s)
Send me a brochure
Send me an application

 

County Office
Hospital
Newspaper Add
Printed Material
Radio
Television
Other