Centauri HS - Best Benefits Eligiblity Screening

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.

This screening is confidential and free to you.

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

How did you hear about us?

Someone we previously assisted
Relative
Friend
Publication
Other

I am completing this form for:

Myself
Child
Other

Name of who needs to file for Social Security Disability Benefits:

First Name: (required)

Last Name: (required)

Address:

City:

State:
Zip:

Phone Number: (required)

Cell Phone:

Opt-in to receive text messages on this line?
Best time to reach you?

Please also provide your E-mail address:

E-mail Address:

Are you currently working?

Yes
No

Are you currently receiving SSI (Supplemental Security Income) for a disabling condition?

Yes
No

Are you currently receiving SSD (Social Security Disability)?

Yes
No

Have you applied for SSI/SSD?

Yes
No

Are you currently being represented by an attorney?

Yes
No

Please provide any medical conditions that currently prevent you or this person from working, completing daily tasks or performing in school (if a child):

Medical Conditions

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

Best Benefits Pre-Screening