It's easy to apply! You may apply by printing the application below and mailing, faxing, or delivering your application to a Department of Social Services local office. You may also contact your nearest Department of Social Services office or call 1-800-305-3064 to request an application be sent to you.
Complete all 4 pages if you are interested in coverage for adult parents(s)/stepparent/caretakers and dependent children or pregnant women in the household. If you are only interested in health coverage for children under age 19, complete pages 1 through 3. If you need assistance completing an application contact a Department of Social Services office nearest you or call 1-800-305-3064.
Send proof of all income and expenses from the last 30 days along with the application. Also, send proof of expenses for court-ordered child support paid and child care paid while working. An interview is not required to apply for medical assistance, but you may request one.
The start date of medical coverage depends on the date the application is received by the Department of Social Services. Medical coverage may go back three months prior to the month the application is received in the Department of Social Services if you have unpaid medical bills and you meet eligibility requirements during this time period. If you are interested in eligibility for the prior three months, include proof of income from month(s) prior to the month the application was submitted to the Department of Social Services.