Home Health Aide For Medically Fragile Children Program

To participate in the Home Health Aide for Medically Fragile Children Program:*

I acknowledge that I understand Medicaid eligibility determinations are based on income requirements and that the earned income from my participation will potentially affect my child’s/dependent’s eligibility for Medicaid.

Signature*

Please type your full name.

Form Date Field*

Case Number

Phone Number*

Phone

Send me a copy of my responses