Preparing to serve New York Medicaid members • Application and onboarding in progress
Medicaid Care ScreeningReview the exact form

Non-submitting demonstration

Review the exact AHC HRSN form.

The exact supplied form structure is shown here. Our Unite Us connection is pending. Identifying controls are disabled and empty, and answers are temporary and not submitted. This demonstration is not an eligibility or referral decision.

Exact supplied AHC form

Review the screening form in one place.

This local preview follows the supplied AHC HRSN structure. It is not an application or official screening. Nothing is saved or sent. It does not determine eligibility or connect anyone to a service.

  • Exact supplied question text
  • Temporary selections only
  • No submission
Question 0We use this survey to understand needs our members have which could interfere with good health. We may share your answers with your other health care providers, and with your health plan and social services organizations, so they can determine if you qualify for any free non-medical services that could be helpful. Please check this box if you agree to continue. You can choose not to answer this survey, but we can only check for services if you do answer.
About this local preview: no answers are shared or saved. Temporary selections remain only in this page until you refresh, leave, stop, or reset.

Future secure intake

Secure Unite Us connection coming soon

This inactive preview shows the information the secure connection may request later. These fields cannot accept, save, or send member information.

Connection pending
Future member intake fields

After onboarding, our organization's own secure Unite Us link will replace this shell.