Tewa Roots Society Medicaid Referral Form
Want to see if you qualify for Medicaid in New Mexico? Let us help!

Fill out the following form to schedule an appointment with our Family Coordinator. After you submit this referral form, someone will reach out by phone or email to schedule an appointment to help you enroll in Medicaid within 4 days. 
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Email *
First & Last Name *
Phone Number *
Are you currently involved with or a client of Tewa Roots Society? *
Availability & Scheduling 
Please provide two different possible dates between Monday-Friday during the hours of 10am-3pm that you would like to meet with our Family Coordinator, and we will call you back to confirm the best meeting time based on your answers. 
1st choice date *
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DD
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Preferred time of day for 1st choice  *
Time
:
Second choice date *
MM
/
DD
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YYYY
Preferred time of day for 2nd choice *
Time
:
What to bring
Please bring the following with you (in either a physical or digital form):
  • One (1) form of identification (i.e. driver's license, social security card, birth certificate)
  • One (1) proof of address (utility bill, rent agreement)
  • Your two most recent check stubs (if you are currently employed)
  • Information on any student loans you may have
  • Information on any outstanding medical bills you may have (within the last 3 months)
  • IF you are married and your spouse wishes to apply with you: Identification and financial documents for your spouse (i.e. social security number, paystubs, W-2, citizenship documents)
  • IF you have children under 18 years old whom you are financially responsible for: Relevant identification documentation for your dependent(s) (i.e. social security number)
  • IF you have a disability: Medical records providing proof of disability
  • IF you are recently unemployed (within 60 days): A letter from your employer
Other documents/information may be needed for special or unique circumstances. You can view the exhaustive list on pages 17-19 of the application here. 

Otherwise, you can show up with the documents you have and we will assess your situation during your first appointment to help you gather what you need to apply for benefits as soon as possible!
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