My Situation *
Please select all situations that apply to you
Insurance Information * Select I never had insurance I recently lost insurance coverage I have not had insurance for over 1 year Employment Coverage *
Did you lose your coverage as a result of loss of employment?
Select Yes No COBRA Benefits *
Do you currently receive any COBRA benefits?
Select Yes No Eligible, but cannot afford payment Future Eligibility *
In your best judgment, do you believe that you may become eligible to receive insurance coverage again in the next 3 months?
Select Yes No Insurance Issue *
Please select all that applies to your situation
No Plan Benefits *
Check all the medical services that you believe you require for which your plan does not provide coverage.
Deductible Amount *
What is the deductible amount on your insurance plan?
Co-Insurance Percentage *
What percent of co-insurance are you responsible for based on your co-insurance? Often this is an amount between 10%-50%.
Benefit Denial *
Check only the medical services which were denied by your insurance carrier.
Other Issue *
Your situation appears unique. Please provide us with a detailed description of the issue you are experiencing with your insurance plan to help us with our evaluation. Please note that applications with this option selected will require additional processing time.
Type of Insurance *
Please tell us what type of insurance plan you currently have.
Select Medicaid Medicare HMO PPO Tricare (or other government type) Household Size *
How many people reside in your householder? We need this information to calculate how your income relates to the national poverty line.
Select 1 2 3 4 5 6 7 8 9 10 Welfare Benefits *
Do you receive any Government Welfare Benefits?
Select Yes No Identify Welfare Benefits *
Which Welfare Benefits do you receive? Check all that apply.
Adverse Life Event *
Please select from any of the below adverse events that apply to your situation.
Family Member *
We are very sorry for your loss. Please tell us who passed away.
Select Spouse Significant Other Child Other Dependent Accident Information *
Please provide us with more information about your accident. Please describe how this situation affects your healthcare situation.
Illness Information *
Please provide us with more information about the illness and how it has affected your healthcare situation.
Natural Disaster *
Please tell us what happened.
Select Flood Fire Earthquake Tornado Hurricane Other Natural Disaster Effect *
Please tell us how this natural disaster has affected you (ie: loss of residence or automobile, damage, injury, etc).
Current Residence *
Have you relocated to a new residence that you are financially responsible for?
Select Yes No, moved in with friends or other family No, I am currently homeless Job Loss *
How recent was your loss of employment?
Select Within the past year Longer than 1 year ago Unemployment Benefits *
Do you currently receive unemployment benefits of any kind?
Select Yes No Monthly Amount *
What is the approximate monthly amount you currently receive via unemployment benefits?
Disability Effect *
We are sorry to hear about your disability. Please tell us more about your situation and how it has affected you (ie: unable to earn income, financial hardship, etc).
Other Details *
Please tell us more about your situation. Since you do not fall within our usual category, please provide specific information about your adverse life event and how it has affected your ability to obtain healthcare.