SJRMC Quick Screen - The Midland Group

SJRMC Medicaid Screening Form

How many people are in your household? *

Have you received or will you be receiving services at San Juan Regional Medical Center or one of their facilities? *

Are you a resident of New Mexico? *

Are you Native American? *

Are you a Veteran? *

Are you the victim of a crime which resulted in this hospital visit? *

Was your visit due to an accident or injury? *

Are you pregnant? *

Are you 65 years of age or older? *

Patient Refused Screening *

Encounter Number

other ways to find out if you qualify

Phone