Uniform County Medical Assistance Application

MEDICAL ASSISTANCE

USE THIS FORM ONLY FOR ASSISTANCE WITH:

• Medical Bills
• Medication Costs
• Cobra Insurance Premiums

Please note that the medical application does require a lot of information.  This is required by state law as all applications received by Indigent Services are shared with the Department of Health and Welfare to determine if the applicant is eligible for Medicaid payment of the medical services.  Thank you for your patience and please be sure to complete the entire application.

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Medical Application