Follow the steps to successfully complete your application

1. Press the ‘Get Form’ button to access the form and open it in the editor.
2. In the first section, provide details about the individual in your household eligible for health insurance from their employer or another source. Include their first name, last name, Medicaid ID number if applicable, social security number, address, city, state, ZIP code, date of birth, email, and the best phone number to contact.
3. Next, describe the health insurance or COBRA benefits available to the person from Step 1. This includes the health insurance company's name, address, policy ID number, group number, policy start date (if applicable), monthly premium, and whether the coverage is COBRA.
4. Provide the name and contact information of the employer or company offering the health insurance or COBRA. Include the employer's name, phone number, address, city, state, and ZIP code.
5. Enter the Medicaid case number for your family, found on your Medicaid ID card. Then, list all family members enrolled in Medicaid. For each member, provide their first name, last name, Medicaid ID number, date of birth, and indicate if they are pregnant along with the due date if applicable.
6. Finally, submit your completed form along with any required documents, such as your employer’s Summary of Benefits and Rate Sheet, and if applicable, a copy of your insurance card. You can fax these documents for quicker processing at 1-866-409-1188 or mail them to HIPP Program at P.O. Box 201120, Austin, TX 78720-9774. For assistance, you can call 1-800-440-0493.

Complete your documents online today for a smoother application process.