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Taking Control
Consumer Application
First Name
Last Name
Street Address
City
State
Zip
County Resident of
Erie County
Niagara County
Franklin County
Medicaid Eligible
N
Y
Phone
Cell Number
Email Address
Prefered method of contact?
Email
Phone
Cell Phone
US Postal Service
Quick description
of needs
Currently have aid service?
No
Yes
Do you currently have a medicaid case worker?
No
Yes
Temporary or permanent Disability?
(6 mo usage req)
Temporary (shorter then 6 months) - Ineligible
Temporary 6 months to a year
Longer term
