Enrollment Form – Gov Paycard Services

Pre-Qualification Questionaire

First Name *

Last Name *

Phone *

Email *

Are you 18+ years old? *

YES

Are you a U.S citizen? *

YES

Do you know someone with Medicaid or have it? *

YES

I agree to receive SMS/text messages from Gov Paycard Services regarding account updates, training reminders, compliance notifications, and customer support. Message frequency varies. Msg & data rates may apply. Reply STOP to opt out or HELP for assistance. I understand that consent is not a condition of receiving services.