Great, you may qualify for the 1915(i )Program!

Please complete the following information:

Please enter your data of birth:

Please enter your address, city, state, and zip code:

Please provide your phone number (landline, cell, and/or work):

Note: start typing in your phone number and it will be automatically formatted.

Add an alternate contact if you would like:

(An alternate contact may be a family member, friend, someone assisting with completion of the eligibility application, or someone who knows the applicant's situation. If no other alternate contact exists, a 1915(i) provider may serve as the alternate contact on the initial eligibility application. By completing the following section, you grant permission for the ND Department of Health and Human Services, its Managed Care Organization, and the Human Service Zone to contact the alternate contact identified on this application.)