Medicaid and CHIP Enrollment Form
Use this form to provide the information needed to start a Medicaid and CHIP enrollment request. The exact same title must appear consistently throughout the form.
Applicant Information
Applicant full name
*
First Name
Middle Name
Last Name
Date of birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sex
*
Female
Male
Intersex
Prefer not to say
Phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Email address
example@example.com
Home address
*
City
*
State
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Other
ZIP/postal code
*
Household and Enrollment Details
Household size
*
Number of children needing coverage
*
Program type
*
Medicaid
CHIP
Both
Current insurance status
*
No current coverage
Employer-sponsored coverage
Marketplace coverage
Other public coverage
Other
Preferred contact method
*
Please Select
Phone
Email
Mail
Text message
Other
Preferred language for communications
*
Please Select
English
Spanish
Chinese
Vietnamese
Arabic
French
Other
Eligibility and Submission Information
Annual Household Income Range
*
Please Select
Under $20,000
$20,000-$39,999
$40,000-$59,999
$60,000-$79,999
$80,000-$99,999
$100,000 or more
Prefer not to say
I confirm the information I provided is accurate and complete
*
I confirm the information I provided is accurate and complete
Special Circumstances or Enrollment Notes
Submit Enrollment
Should be Empty: