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It's easy to apply for CHIP! You may apply by printing the CHIP 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 pages 1-3 of the application for health coverage for children under age 19. If you are interested in coverage for adult parent(s)/caretakers or pregnant women in the household, please complete page 4 of the application as well. If you need assistance completing an application, contact a Department of Social Services office 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.
The start date of medical coverage depends on the date the application is received by the Department. An interview is not required to apply for medical assistance, but you may request one.
Medical coverage may go back three months prior to the month the application is received by the Department, 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 the month(s) prior to the month the application is submitted to the Department.
