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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 code
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(Please enter your telephone number in the format 123-456-7890.)
Day telephone
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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?
County Arkansas Ashley Baxter Benton Boone Bradley Calhoun Carroll Chicot Clark Clay Cleburne Cleveland Columbia Conway Craighead Crawford Crittenden Cross Dallas Desha Drew Faulkner Franklin Fulton Garland Grant Greene Hempstead Hot Springs Howard Independence Izard Jackson Jefferson Johnson Lafayette Lawrence Lee Lincoln Little River Logan Lonoke Madison Marion Miller Mississippi Monroe Montgomery Nevada Newton Ouachita Perry Phillips Pike Poinsett Polk Pope Prairie Pulaski Randolph Saline Scott Searcy Sebastian Sevier Sharp St. Francis Stone Union Van Buren Washington White Woodruff Yell State of Louisiana State of Missouri State of Mississippi State of Oklahoma State of Tennessee State of Texas All Other States
Please describe yourself.
Possible participant Medicaid provider Other
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
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Your sex
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What do you have questions about? (click all that apply)
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Type any other questions in this box:
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How did you hear about the ARKids First program?
County Office Hospital Newspaper Add Printed Material Radio Television Other
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