Eligibility/How To Apply

SHCN

Financial Eligibility
Financial eligibility is based on family income and size. The Financial Eligibility Guidelines show maximum earnings per family size.

Family income is determined by your IRS income tax form. This form is required with your application for services. Income consists of the Adjusted Gross Income (AGI) of the Federal IRS income tax form. An estimated income can be substituted for the AGI when no income tax form is available or when the income tax form is not available or when the income tax form is not reflective of the family’s current financial status.

Family size is determined by the number of person(s) listed on your income tax form, if available. Your local SHCN office can help you determine financial eligibility.

How to Apply
Contact any of the regional offices for an enrollment form or download a form at the below link.

Enrollment form, CC-1, can be printed by selecting the links below:

English
Spanish (Español)
Bosnian
Russian
Vietnamese

(Requires Adobe Acrobat. Click here for free download.)

Be sure to print both pages. The second page provides instructions on filling out the application. You can take the form to your local SHCN office. They can help you fill out the form or send the form to SHCN.