Financial Screening Application

Please complete this form if you would like to apply for discounted STRIDE coverage, renew your STRIDE discount coverage or if you need assistance applying for Medicaid. You may be eligible for a STRIDE discount even if you have other coverage.

Applicant Information

Applicant Medical Coverage Information

If yes please upload a picture of the insurance card at the end of this form

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How to apply for Medicaid

The applicant can apply for Medicaid online at Colorado PEAK or at a self service kiosk at STRIDE's Peoria Clinic. If the applicant needs assistance applying for Medicaid, a STRIDE Enrollment Specialist can assist you by appointment.

Would the applicant like to make an appointment to receive assistance applying for Medicaid?

Applicant Income Information

Does the applicant have income?
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How often does the applicant receive a paycheck?

This will be the gross income amount from a paycheck stub

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Applicant Household Information

Is the applicant currently pregnant?


What is the applicant's estimated due date?

Who is included in household size?

Spouse or partner

Children under 18

Disabled adult children

Adult children that are full-time students (Please upload previous year tax form)

Unborn children

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Household Member #2 Information

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Does household member #2 have Medicaid or CHP+?
Is household member #2 applying for coverage?
Does household member #2 have a source of income?
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How often does household member #2 get paid?

This will be the gross income amount from a paycheck stub

Household Member #3 Information

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Does household member #3 have Medicaid or CHP+?
Is household member #3 applying for coverage?
Does household member #3 have a source of income?
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How often does household member #3 get paid?

This will be the gross income amount from a paycheck stub

Household Member #4 Information

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Does household member #4 have Medicaid or CHP+?
Is household member #4 applying for coverage?
Does household member #4 have a source of income?
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How often does household member #4 get paid?

This will be the gross income amount from a paycheck stub

Household Member #5 Information

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Does household member #5 have Medicaid or CHP+?
Is household member #5 applying for coverage?
Does household member #5 have a source of income?
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How often does household member #5 get paid?

This will be the gross income amount from a paycheck stub

Household Member #6 Information

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Does household member #6 have Medicaid or CHP+?
Is household member #6 applying for coverage?
Does household member #6 have a source of income?
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How often does household member #6 get paid?

This will be the gross income amount from a paycheck stub

Household Member #7 Information

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Does household member #7 have Medicaid or CHP+?
Is household member #7 applying for coverage?
Does household member #7 have a source of income?
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How often does household member #7 get paid?

This will be the gross income amount from a paycheck stub

Household Member #8 Information

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Does household member #8 have Medicaid or CHP+?
Is household member #8 applying for coverage?
Does household member #8 have a source of income?
Select or enter value
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How often does household member #8 get paid?

This will be the gross income amount from a paycheck stub

Household Member #9 Information

Select or enter value
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Does household member #9 have Medicaid or CHP+?
Is household member #9 applying for coverage?
Does household member #9 have a source of income?
Select or enter value
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How often does household member #9 get paid?

This will be the gross income amount from a paycheck stub

Please upload the below documents

Identification

Please upload one of the below documents


US passport, Naturalization Certificate, Birth Certificate, State Driver’s License, State Identification Card, Military ID, Resident Card, Work Permit, Immigration Cards, Matricula Consular/Elector ID

Applicant Income Document

Paystub from current or previous month or if paid in cash an income letter from employer stating gross income/ hourly wage/ hours worked for previous month

Spouse or Partner Identification


US passport, Naturalization Certificate, Birth Certificate, State Driver’s License, State Identification Card, Military ID, Resident Card, Work Permit, Immigration Cards, Matricula Consular/Elector ID

Household member #2 - Income Document

Paystub from current or previous month or if paid in cash an income letter from employer stating gross income/ hourly wage/ hours worked for previous month

Self Employment Income

Profit/loss statement or ledger showing your gross income and business expenses from previous month.

Proof of Medical Expense

A current receipt that reflects the payments you are making needs to be provided to be considered as an allowable deduction

Medicaid/ Medicare or Private Insurance Card

Consent To Virtual Financial Screening

By submitting this application you are consenting to a virtual financial screening appointment. To see STRIDE's telehealth consent policy please click here.

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