Exit Survey and return to Human Arc

Hello! Thanks for visiting our benefits pre-screening web page. This is a secure site. Your information will not be shared or sold and we will use this information for the sole purpose of determining eligibility for the program. Your participation is voluntary and will not affect your benefits as a health plan member. The appropriate government agency will make the final eligibility determination.

We work on behalf of your health plan, and this screening is confidential and free to you.

The questions are simple, and this should only take a few minutes.

Please provide your member number identified on the letter you received:
Name of Health Plan:
I am completing this form for:
Member Information:

Please also provide your E-mail address:
Are you currently working?
Are you currently receiving SSI (Supplemental Security Income) for a disabling condition?
Are you currently receiving SSD (Social Security Disability)?
Have you applied for SSI/SSD?
Are you currently being represented by an attorney?
Please provide any medical conditions that currently prevent this member from working, completing daily tasks or performing in school (if a child):

Thank you very much! Now just click on the "Done" button...