Who is filling out the application?

What is your relationship to the applicant?

Choose the one that best describes your relationship to the applicant.

What is the name of the individual applying for BDS Services?

Please enter a first and last name for the applicant. Middle name and suffix are optional.

What is the applicant's social security number?

If you do not have a social security number (SSN), select ITIN and enter your ITIN. Enter either your SSN or ITIN as numbers with no hyphens. BDS is requiring disclosure of your social security number per IC 4-1-8-1. The information obtained on this form is confidential under state and federal regulations. This information will not be released except as permitted or required by law or with the consent of the applicant.

What is the applicant's date of birth?

Please enter in the following format: XX/XX/XXXX. You do not need to add a zero at the beginning of single digit months or days.

Does the applicant currently have Medicaid?

The applicant is not required to have a Medicaid number to apply for BDS services. Select "Yes" if the applicant has a Medicaid number.

What is the applicant's Medicaid number?

A Medicaid number is also known as a RID which means Recipient Identification. This is a 12-digit client identification number and is found on the Medicaid card issued to the applicant. If the applicant does not have or does not know this number, leave this blank and move to the next question.