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The employer or COBRA plan. Enter the earliest enrollment date in month/day/year format. Please read the authorization section carefully and sign the Health Insurance Premium Payment Program Application/Renewal Form. Attach a copy front and back of all health insurance cards Medical Dental Pharmacy copy of your latest pay stub and a copy of the Summary of Benefits this is a summary of what is covered under the insurance plan to your Health Insura.

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Related content

Department of Medical Assistance Services.Medicaid...
The CHIP program in Virginia is called Family Access to Medical Insurance ... Our mission...
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NY DTF ET-706-I 2014 NY DTF ET-706-I 2012 NY DTF ET-706-I 2011 NY DTF ET-706-I 2010

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Cover Virginia also operates a statewide customer service call center for Medicaid and the FAMIS Programs at 1-855-242-8282. The call center provides general program information, application status, explanation of coverage and benefits, and assistance in resolving application issues.

For assistance with billing, claims, member eligibility, memos and other regulations, call the Virginia Medicaid Provider Helpline at the toll-free (800-552-8627) or in-state (804-786-6273) phone numbers. The Provider Helpline is available Monday to Friday between 8am and 5pm.

Region RegionAddressHarrisburg Regional OfficeP.O. Box 8195 Harrisburg, PA 17105-8195 1-800-644-7730Torrance Regional OfficeP.O. Box H Torrance, PA 15779-0115 1-800-684-7730Warren Regional Office589 Hospital Drive, Suite D Warren, PA 16365 1-800-440-93912 more rows

To check your status, you can log in to your account at commonhelp.virginia.gov by clicking the Check My Benefits button or call 1-855-242-8282 (TDD: 1-888-221-1590).

To check your status, you can log in to your account at commonhelp.virginia.gov by clicking the Check My Benefits button or call 1-855-242-8282 (TDD: 1-888-221-1590).

Change Your Health Plan For Medicaid Enrollment. Web: .coverva.org. Tel: 1-833-5CALLVA. TDD: 1-888-221-1590.

VIRGINIA MEDICAID OVERVIEW The Virginia Department of Medical Assistance Services (DMAS) plays an essential role in the Commonwealth's health care system by offering lifesaving coverage to one in five Virginians.

The Health Insurance Premium Payment (HIPP) program HIPP pays all or part of the family's group health insurance premium (monthly cost). HIPP is for members who have employer-sponsored group health insurance available to them through their own or their family member's employment.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232