Welcome

Looking for low-cost health insurance options? Community Health Plan may be able to help.

To see what programs you may qualify for, please fill out the form below. Community Health Plan will send you information about health insurance options that may be right for you and your family.

Male Female

Are you a current member of Community Health Plan?

Yes No

Do you have health insurance for: (check all that apply)

  Myself only   My Children Only
  My Family & Myself  I don't have health insurance

May we contact you with information about free or affordable health insurance?

Yes No

What language do you speak at home? (check all that apply)

  English   Russian   Mandarin
  Spanish   Cantonese   Vietnamese
Other:

How did you hear about today's event?

  Newspaper or Radio   Doctor's Office   Friend or Family
Other: