Alaska Health Insurance Premium Payment Program
Fill out this form. Then click Submit to send it to us.
Apply Now
*Required fields.
Step 1. How did you hear about AK HIPP?*
Step 2. Describe the person in your family who is able to receive commercial health insurance at work, through an individual commercial health insurance plan, or choosing continuing coverage through COBRA (Consolidated Omnibus Budget Reconciliation Act).
First name:
*
MI:
  
Last name:
*
Suffix:
  
Social Security number:
*
Date of birth:
*
"MM/DD/YYYY"
Address:
*
Apartment/Lot #:
  
City:
*
State
*
Zip:
* -
Best phone number to call:
*
Email
  

Step 3. Describe the commercial health insurance or COBRA benefits the person in Step 2 is able to receive. (COBRA gives workers and their families who lose their health benefits the right to choose to continue group health benefits provided by their group health plan for limited period of time under certain circumstance such as voluntary or involuntary job loss.)
(COBRA is a type of health insurance you can get if you leave a job where you had a health plan.)
Health insurance company name:
  
Insurance company address:
  
City:
  
State
  
Zip:
   -
Health plan name:
  
Policy ID number
  
Group number:
  
Policy start date:
  
"MM/DD/YYYY"
Monthly insurance premium
  
  

Is this COBRA insurance?
Yes No

Check the box next to the items your insurance covers:
Doctor VisitsMedicineHospital StaysLab and X-RayOutpatient Hospital

Step 4. Tell us about the employer or other place that offers health insurance or COBRA.

Employer or company name:
  
Address:
  
City:
  
State
  
Zip:
   -
Phone:
  

Step 5. Tell us about the family members who get Medicaid.

First name:
*
MI:
  
Last name:
*
Suffix:
  
Medicaid ID:
  
Social Security number:
*
Date of birth:
*
"MM/DD/YYYY"

Is this person pregnant?
Yes No


Enter the numbers shown below in to the box provided before clicking Submit.

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Please call us at (866)251-4861 or send email to CustomerService@MyAKHIPP.com if you experience problems with this form.

No time to fill out online? Download the Alaska HIPP Program Application to fax or mail to us.

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