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I need more information

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