Helping Hand Program For The Uninsured Eligibility Form

To be eligible for assistance each applicant must meet minimum gross income requirements set by the Federal Government.

Step 1: Determine if you meet this initial criteria by completing the form below.
Step 2: If it is determined if you may be eligible for assistance, you will then be asked to complete an application form.

Required fields *

Number of Persons in Family/Household: * 1 2 3 4 5 6 7 8 9 10

Sources of income: (if married, both required) * Source: Annual amount (numeric only)