Enrollment Entity #90692

The Healthy Families Program offers: HEALTH, DENTAL and VISION coverage for children living in California

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For Help with your Annual Eligibility Review (the yearly Healthy Families renewal process) click here

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We are an authorized Enrollment Entity for the State of California Healthy Families Program and Medi-Cal for Children and Pregnant Women, (EE- #90692). We are not a State agency.

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Applying for the Healthy Families Program and Medi-Cal for Children and Pregnant Women is FAST and FREE

We are an authorized Enrollment Entity (#90692) for the California Healthy Families Program and Medi-Cal for Children and Pregnant Women. Our business is to make sure your application is prepared quickly, efficiently and accurately at no cost to you.

The California Healthy Families Program offers low cost health insurance for children until their 19th birthday. This includes Health, Dental and Vision coverage for qualifying applicants.

Medi-Cal Coverage is also available. If you do not qualify for the Healthy Families Program, you may qualify for Free Medi-Cal.

A California State Certified Application Assistant will call to assist you with the application process. Our service is fast and free . At the end of a 10 minute phone call the Certified Application Assistant will tell you whether you are likely to qualify for the Healthy Families Program or Medi-cal and what the estimated cost will be for your child's health care coverage. You may ask the Certified Application Assistant any questions you have regarding health care options for your children.

Please fill out the form below to be contacted by a Certified Application Assistant within 24 to 48 hours. Be sure to choose the best time for you to be called and double check that your phone numbers are entered correctly.

Applicant Information

* asterisk indicates mandatory field

YOUR First Name (Adult):
^*

YOUR Middle Initial (Adult):

YOUR Last Name (Adult):
^*

Email Address:
^*
Get free email at Hotmail.com

	Home	Telephone
	( )	^* ext
Example:	(XXX)	XXX-XXXX

	Prefered ( )	Telephone ext
Example:	(XXX)	XXX-XXXX

	Cell ( )	Phone
Example:	(XXX)	XXX-XXXX

Number of Children to be covered

*We will attempt to call you within 30 minutes of your desired hour

I prefer to be called between
^*

Children to be Covered

Child-1
First Name: ^*	Last Name: ^*
Date of Birth: ^*

Child-3
First Name:	Last Name:
Date of Birth:

Child-2
First Name:	Last Name:
Date of Birth:

Child-4
First Name:	Last Name:
Date of Birth:

Address Information

Address:	Address #2:
City:	State:
Zip:	County:

Family Information

What is your family size? * Please include the following family members
All adults and children under 19 years of age living in the home. The unborn child of a pregnant woman also counts as a family member. Yourself. ^*

Number of Incomes: How many members of your family receive an income?

What is your family's Gross Monthly Income (before deductions)? $ ^*

Please only click once.

Note: This is only a reuest for assistant and not an official State form, and should not be used as such. A Certified Applicant Assistant will contact you to complete the process of enrollment and answer your questions. * Your Privacy Rights are Reserved.

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