Healthcare Access Project Intake

The best way for most people to get help with your Medicaid benefits from Legal Services of South Central Michigan (LSSCM) is to apply for help online.

To apply online:

You will need a phone number or email address where we can safely reach out, and
You must live in Michigan.

If you are unable to apply online, you can apply over the phone at (734) 665-6181 ext. 170.

All of your answers are private and will not be shared with anyone outside of Legal Services of South Central Michigan.

After you submit your application, we will review it. We will call or email you within two business days of when you submit your application.

We care about your safety and privacy.

This is a secure website. But if you are using a public or shared computer, close the Internet browser when you are done. If you don’t, you might accidentally share your personal information with someone else.

If you fear for your safety where you are now, please do not use our online application. Please call us instead. You can call us at (734) 665-9181 ext. 170.

I understand, agree, and want to continue.

YesNo

This is an application for legal help. We do our best to help everyone in Michigan who has a low income, but we may not be able to take your case because there are more people who need our services than we can help. Filling out this application does not guarantee you will get a lawyer.

Do you understand that completing this application does not guarantee that you will get help, and does not create an attorney-client relationship with Legal Services of South Central Michigan?

I understand and want to continue.

YesNo

Authorization to continue

If you are concerned about either your privacy or your safety, and have decided not to use our online intake application. Please call us instead. Return to the MichiganLegalHelp.org page showing your Guide results and find your local office's phone number and hours. If you change your mind and want to finish applying for help online, you must agree to continue by clicking Yes above.

Authorization to continue

We're sorry, you cannot continue unless you understand and agree to the terms of use.

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Authorization to Continue

Legal Services of South Central Michigan (LSSCM) is unable to assist you because you live outside of our counties served. Please consult one of the legal aid offices in your service area.

Legal Services of Eastern Michigan, (800) 322-4512:
Arenac, Bay, Clare, Genesee, Gladwin, Gratiot, Huron, Isabella, Lapeer, Midland, Saginaw, Sanilac, St. Clair, and Tuscola counties

Legal Aid of Western Michigan, lawestmi.org:
Allegan, Berrien, Cass, Ionia, Kalamazoo, Kent, Lake, Mason, Mecosta, Montcalm, Muskegon, Newaygo, Oceana, Osceola, Ottawa, St. Joseph and Van Buren counties

Lakeshore Legal Aid, (888) 783-8190:
Macomb, Oakland, and Wayne counties

Legal Services of Northern Michigan, https://www.lsnm.org/: All other Michigan Counties

Name

First Name

Middle Name

Last Name

Suffix

If you do not have a middle name, type N/A

Other Information

Date of birth

Enter the date manually in the format MM/DD/YYYY, or use the calendar to make your selection.

If you are NOT a U.S. Citizen or LPR, please call (734) 239-7018 or email hap@lsscm.org.

Marital Status

Pick the one that best describes your marital status

Social Security # xxx-xx

Last 4 digits only

Please Select the options that most clearly reflect your identity

Gender

Ethnicity

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Contact via Email

We generally communicate with our clients about their legal problems through email. Can we communicate with you via email?

Yes, I will check my email for communication about my case.No, I do not use email.

Please provide an alternate method for us to communicate with you:

PhoneTextUSPS Mail

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Address

Street

City

State

Zip Code

County

Is it safe to send you mail to this address?

Yes
No

Is the mailing address the same as above?

YesNo

Mailing Address

My mailing address is a post office box

Street

City

State

Zip Code

County

What best describes where you are living?

If residence is a mobile home, what is rented?

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Best time to contact you

We'll be calling you to talk more about your legal problem. When is it best for us to call you?

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Is someone helping you with this application, such as a social worker, neighbor, or relative?

Yes
No

Permission to Refer

Helper, do you have the client (friend, neighbor, or relative)'s permission to refer their case to LSSCM?

YesNo

Helper's Contact Information

First Name

Initial

Last Name

Suffix

Agency

Phone

Helper's Email

If we cannot reach the client, can we contact you?

Yes
No

Helper authorization

You can NOT complete this form without getting the client (friend, neighbor, or relative)'s permission. This permission is necessary because without it LSSCM will not be able to reach out to the client and offer assistance. Correct your answer above after you get the permission.

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Adults

How many adults live in your household?

Count people 18 and over, including yourself if you are an adult. If you need help getting separated from someone who lives with you, don’t count that person.

Children

How many children live in your household?

Count people under 18, including yourself if you are under 18.

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Military Service

Are you a veteran?

YesNo

Does any other member of your household serve in the military now or did they serve in the past?

Yes
No

Disability

Do you have a disability?

Yes
No

Please describe your disability

Farmworker status

Have you been a Farmworker in the past?

YesNo

Select your Farmworker status if it applies

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You must qualify for our services to get help. For this question, we need information about income for every person in your household, except for someone who is the opposing party (such as someone you’re separating from or divorcing). Please include everything: income from work, child support you receive, and benefits like unemployment, Social Security, and cash assistance (FIP). Do not include Food Stamps (FAP) here. Pick an income type to submit information about every kind of income that is brought into your household (except for the opposing party’s income).

For each source of income, select a type, frequency, and amount. If you don't have any income, count incomes for other people in your household. If no one in your household has income, select "No Income".

Your primary income

Income Type

Describe other

Frequency: when are you paid?

Amount

$

Do you or your household have any additional income? *

Yes

No

Remember to include income from every person in your household except for the opposing party

Include income from every person in your household except for the opposing party

Income Type

Describe other

Frequency: when are you/they paid?

Amount

$

Do you receive food stamps?

YesNo

Amount per month

$

Do you expect your household income to change in the near future?

No, my/our income is NOT likely to change in the near futureYes, my/our income is likely to go UP in the near futureYes, my/our income is likely to go DOWN in the near future

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We know you are seeking help with a Medicaid issue. Please describe the issue you are having. Include whether you are currently on Medicaid, have applied for Medicaid, or have been denied. If you have a Michigan Department of Health and Human Services case, include your case number.

For example, if you are being evicted: “I want to stay in my home.” OR “I want to move, but I need more time.” If your case involves DHHS: “I want to get my food stamps back.” Or, in a family matter: “I want to get a divorce. And I will need child support.”

Other Legal Problem (600 characters max)

If you have any other legal problems, please quickly mention them here. We will ask you about it when when we talk to you. Do not submit another application.

By clicking "submit" you send your application to Legal Services of South Central Michigan. We will call or email you within 2 business days to let you know if we can help you. For your privacy, this call will come from a blocked number.

You do not need to call us, but if you do, please tell us about your online application when we talk. Thank you!

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