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1) Please indicate how you would prefer to to pay for the services of an attorney, should you hire one to help you with your legal matter. Note: there is no charge to sumbit your request.  [required]
Hourly Rate
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2) Who is seeking Medicaid coverage?  [required]
3) How old is the person seeking Medicaid coverage?  [required]
4) Which of the following describe the person seeking Medicaid coverage? Check all that apply.  [required]
Blind
Family with Dependent Children
Disabled
Elderly
Low Income
None of the Above
5) In what state is the person seeking Medicaid coverage located?  [required]
6) What medical services are needed? Check all that apply.  [required]
Clinic Services
Dental Care
Foot Care
Hospital Services
In-home Nursing Care
Laboratory and X-ray Services
Medical Equipment
Nursing Home Care
Optometry Services
Physician Services
Prescription Drugs
Rehabilitative Services
Transportation to Receive Medical Care
7) Has a claim for Medicaid coverage been made already?  [required]
Yes  No
8) If so, was this claim denied?
Yes  No
9) Comments or Details:

I want responses from Lawyers that serve:  [required]
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ZIP Code:  -- OR --
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Contact Information:
11)
First Name: [required]
 Last Name: [required]
12)Email Address: [required]
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Day Time Phone: [required]
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Best Time: [required]

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