ELIGIBLE

1. Are you or your loved one 55 years of age or older (or will be in the next 3 months)?*

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1a

2. Do you or your loved one have difficulty with any of the following tasks and would benefit from assistance? Check all that apply:*

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2a

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2b

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Please do not specify additional checkmarks when choosing "not applicable."

3. Do you or your loved one use any of the following treatments or have any of the following conditions? Check all that apply:*

If "Other," please specify:

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3a

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3b

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Please do not specify additional checkmarks when choosing "not applicable."

4. Do you or your loved one have Medicaid?*

5. What is the permanent zip code of you or your loved one?*

ZIP Code

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Final Tally

Comments

This field is for validation purposes and should be left unchanged.

Are you eligible for PACE? Take the Quiz.