Exit Survey and return to Human Arc

Hello! Thank you for visiting our benefits pre-screening web page.

This is a secure site. This screening is confidential and free to you. The questions are simple, and this should only take a few minutes.

EligibilityEnrollmentSolutions
Please provide the identification number from letter received.
Please enter your name as it is listed on the letter you received:


What is your state of residence?
What phone number and time of day are best for you to be contacted?


If you would like to receive communication from Human Arc via email, please provide your email address:
Does the patient have health insurance?
No
In the following tables, fill in the values based upon all assets owned by the people currently living in your "home" that can be counted as part of your "household group".
Household Group - Answer this question as if you are one of the adults responsible for supporting the household. Based upon this, the following individuals are to be included if they are living in your home: Yourself, your spouse, your partner if you have a child between the two of you who is not married, under 18 and still living in your home, any natural or adopted children if they are under 18 and not married. Do not include your parents if you are over 18 years old.
Income:
Admit Month

Resources:
Estimated Value

Is the patient married?
No
Is the patient under the age of 18?
No
Is the patient between the ages of 19 and 21?
No
Is the patient pregnant?
No
Does the patient have biological or adopted children in the household who are under 18 years of age?
No
Does the patient have any of the following conditions:
Has the patient been told by a doctor that he/she is unable to work for at least the next 12 months, due to a medical condition?
No

Thank you very much! Now just click on the "Done" button...