Please provide us a little information about yourself so we can mail you the correct paper application.

EnglishSpanishNeither
Application for health care coverage
Application for health care coverage, food assistance, and cash programs
YesNo
Do you believe you have a disability? (even if you have been denied disability status by the Social Security Administration)
Are you under the age of 64?
YesNo
Child age 0-15 for whom no other acceptable identity documents are available, such as: clinic, doctor, hospital, or school records
Individual age 16-18 for whom no other acceptable identity documents are available, such as school ID cards and drivers' licenses
A disabled individual in an institutional care facility for whom no other evidence of identity is available