Caring support
for your family,
at no cost to you.

Are you in the medically enhanced population enrolled in a regular Medicaid insurance plan? *

Not Essential Plan and not straight Medicaid.

Is a member of your household in the medically enhanced population enrolled in a regular Medicaid insurance plan? *

Not Essential Plan and not straight Medicaid.

Select your medically enhanced category *

Is the eligible member pregnant? *

What is the due date? *

Do you have a baby under the age of one? *

What is your baby's date of birth? *

Enter the CIN ID of the eligible member *

As it appears on the insurance card. The CIN ID is an 8-character Medicaid ID: two letters, five numbers, then a letter, for example AB12345C. Do not enter your insurance member ID.

What is the eligible member's name? *

As it appears on the insurance card.

What is the eligible member's date of birth? *

Other household members on Medicaid (optional)

Enter the full legal name, date of birth, and CIN ID for all other members in your household enrolled in a regular Medicaid insurance plan (not Essential and not straight Medicaid).

What is your address? *

How can we reach you? *

Do you consent to, and can your primary phone receive, SMS text messages? *

Secondary phone (optional)

Are you concerned about food security and would like to enroll in the Medicaid waiver nutrition program? *

Do you need ready-prepared meals, or are you able to cook your own meals using raw grocery items? Note: switching between groceries and meals later requires a reauthorization, wait time, and a possible lapse of service.

Select your preferred caterer (optional)

Any allergies or dietary restrictions? (optional)

Please specify any allergy or dietary restrictions in your household.

Are you or anyone in your household currently employed? *

Are you currently receiving WIC? *

Are you currently receiving SNAP? *

Have you previously received Provision services? (optional)

Are you affiliated with one of our partner communities? (optional)

If so, would you like your community representative to process your application?

How did you hear about this program? (optional)

Anything else you'd like us to know? (optional)

Review & submit

Please confirm the security check below, then submit your registration. A Provision team member will review it and contact you.

Your information is private and secure. We only use it to determine eligibility and provide support.