3M MEDICAID QUESTIONNAIRE

Please complete this brief form. ALL fields are required.

First Name *

Middle Name

Last Name *

Date of Birth - please use format (MM/DD/YYYY) *

Street Address *

City *

State *

Zip Code *

RESPOND YES OR NO TO THE QUESTION BELOW

Have you ever used Medicaid for medical care related to either hearing loss or tinnitus (ringing in your ears)? You must answer YES or NO *

Yes

Please Verify You Are a Human