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Provider Connect Home

Consumer Registration

All fields marked with an asterisk (*) are required.
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*Registration Start Date (MMDDYYYY)
 
*Receipient ID(RIN)
Client ID
*Agency FEIN
Satellite Code
*Medicaid Site ID

Demographics
*Last Name
*First Name
Middle Initial
Suffix
*Date of Birth (MMDDYYYY)
 
*Mother's Maiden Name
*Social Security Number

UnknownNo SSN
*Gender
Male
Female
*Primary Address
Address Line 2
*City
*State
*ZIP
ZIP Suffix
Address Unknown
*County
*Township/Community Area
*Household Income
Unknown
*Client Income
Unknown
*Household Size
Unknown
*Household Composition
*Education Level
*Military Status
*Marital Status
*Employment Status
*SSI-SSDI Eligibility
*DFI-CFI Enrollment
*Court/Forensic Treatment
*Race 1
*Race 2
*Race 3
*Race 4
*Citizenship
*Race 5
*Hispanic Origin
*Language
*Interpreter Services Needed
*MH Residential Arrangment
Justice System Involvement
Disaster Guest Type
Disaster Guest State
Disaster Guest County