Better Together ND - 1915(i) Assessment Tool

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

Please complete the following information:

First Name:

Middle Initial:

Last Name:

Date of Birth:

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

Street Address:

City:

State:

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.

Telephone Number:

Cell Phone Number:

Work Phone Number:

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.)

First Name:

Last Name:

Phone Number:

Please provide your email address:

Email Address:

Better Together ND Assessment Tool