your information

Welcome to Healthy Families, the nation's first health insurance exchange. Since 1997 we have helped over one million families and individuals coordinate enrollment between Medicaid, the Children's Health Insurance Program (CHIP), the Pre-Existing Condition Insurance Plan (PCIP), and private health insurance. If you would like to submit a same day application, please complete this short form.

Applicant Information
First Name
 Last Name
Email Address
 Home Phone
()
State
Parent Date of Birth

Program Information
What is your family size? (parents and children under 19 years of age living in the home are counted as family members in determining family income. The unborn child of a pregnant woman also counts as a family member.)
What is your Gross Monthly Income?
$
Would you like health insurance for yourself, your spouse, or your children over the age of 19? Health insurance is now available through the Pre-Existing Condition Insurance Plan (PCIP). You must be a U.S. citizen, have been denied health coverage because of a pre-existing condition, and have had no health insurance for the last 6 months.
Yes  No
Please note that all fields are required.