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

By submitting, you authorize United Home Help Care Inc. d/b/a Gov Paycard Services. to text/call the number above for informational/transactional messages, possibly using automated means. Msg/data rates apply, msg frequency varies. Consent is not a condition of purchase Text HELP for help and STOP to unsubscribe.