Eligibility & Registration

Eligibility screening

Registration

Complete the form below and a Fresh Start team member will review your information. Required fields are marked with *.

These answers help us confirm whether this program may be a fit.

Are you in the medically enhanced population enrolled in a regular Medicaid insurance plan? *

Not Essential Plan and not straight Medicaid.

Yes No

Medically enhanced category *

Enter the eligible member's details as they appear on the insurance card.

CIN ID * Two letters, five numbers, then a letter. Do not enter your insurance member ID. Date of birth * First name * Last name *

Other household members on Medicaid

Add each household member enrolled in a regular Medicaid insurance plan. Include their details exactly as they appear on their insurance card.

Tell us where you live and how we can reach you.

Street address * Apt / unit City * State * ZIP code * Email * Primary phone * 10-digit number. Please use your cell number if possible.

Do you consent to, and can your primary phone receive, SMS text messages? *

Yes No

Secondary phone 10-digit number.

Tell us about the food support and related benefits you may need.

Are you concerned about food security and would like to enroll in the Medicaid waiver nutrition program? *

Switching between groceries and meals later requires reauthorization, wait time, and a possible lapse of service.

Ready-prepared meals Raw grocery items (I cook my own)

Allergies or dietary restrictions

Are you or anyone in your household currently employed? *

Yes No

Are you currently receiving WIC? *

Yes No

Are you currently receiving SNAP? *

Yes No

Share anything else that can help our team follow up.

How did you hear about this program? Anything else you'd like us to know?

This form is not connected yet — submissions are disabled until intake delivery is set up.

Your information is private and secure. We only use it to determine eligibility and provide support.