Online Application for AK HIPP - 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?*Please SelectProgram information mailed to my homeMy Medicaid caseworker gave me program informationA search engine helped me find online information about the programI found program information while on a social network or blogI read about the program in a Medicaid newsletter or publicationA health related support group gave me program informationMy doctor's office gave me program informationMy employer or human resources gave me program informationMy child's school gave me program informationAn employee benefits fair gave me program informationI saw an outdoor program advertisementA friend told me about the program

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:

Please SelectJrSrIIIIIIVVVIVIIVIIIIX

Social Security number:

*

Date of birth:

*

"MM/DD/YYYY"

Address:

*

Apartment/Lot #:

City:

*

State

*Please SelectALABAMAALASKAARIZONAARKANSASCALIFORNIACOLORADOCONNECTICUTDELAWAREDISTRICT OF COLUMBIAFLORIDAGEORGIAGUAMHAWAIIIDAHOILLINOISINDIANAIOWAKANSASKENTUCKYLOUISIANAMAINEMARYLANDMASSACHUSETTSMICHIGANMINNESOTAMISSISSIPPIMISSOURIMONTANANEBRASKANEVADANEW HAMPSHIRENEW JERSEYNEW MEXICONEW YORKNORTH CAROLINANORTH DAKOTAOHIOOKLAHOMAOREGONPENNSYLVANIARHODE ISLANDSOUTH CAROLINASOUTH DAKOTATENNESSEETEXASUTAHVERMONTVIRGINIAWASHINGTONWEST VIRGINIAWISCONSINWYOMING

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

Please SelectALABAMAALASKAARIZONAARKANSASCALIFORNIACOLORADOCONNECTICUTDELAWAREDISTRICT OF COLUMBIAFLORIDAGEORGIAGUAMHAWAIIIDAHOILLINOISINDIANAIOWAKANSASKENTUCKYLOUISIANAMAINEMARYLANDMASSACHUSETTSMICHIGANMINNESOTAMISSISSIPPIMISSOURIMONTANANEBRASKANEVADANEW HAMPSHIRENEW JERSEYNEW MEXICONEW YORKNORTH CAROLINANORTH DAKOTAOHIOOKLAHOMAOREGONPENNSYLVANIARHODE ISLANDSOUTH CAROLINASOUTH DAKOTATENNESSEETEXASUTAHVERMONTVIRGINIAWASHINGTONWEST VIRGINIAWISCONSINWYOMING

Zip:

-

Health plan name:

Policy ID number

Group number:

Policy start date:

"MM/DD/YYYY"

Monthly insurance premium

Is this COBRA insurance?

Yes No      COBRA Start Date: * COBRA End Date:

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

Please SelectALABAMAALASKAARIZONAARKANSASCALIFORNIACOLORADOCONNECTICUTDELAWAREDISTRICT OF COLUMBIAFLORIDAGEORGIAGUAMHAWAIIIDAHOILLINOISINDIANAIOWAKANSASKENTUCKYLOUISIANAMAINEMARYLANDMASSACHUSETTSMICHIGANMINNESOTAMISSISSIPPIMISSOURIMONTANANEBRASKANEVADANEW HAMPSHIRENEW JERSEYNEW MEXICONEW YORKNORTH CAROLINANORTH DAKOTAOHIOOKLAHOMAOREGONPENNSYLVANIARHODE ISLANDSOUTH CAROLINASOUTH DAKOTATENNESSEETEXASUTAHVERMONTVIRGINIAWASHINGTONWEST VIRGINIAWISCONSINWYOMING

Zip:

-

Phone:

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

First name:

*

MI:

Last name:

*

Suffix:

Please SelectJrSrIIIIIIVVVIVIIVIIIIX

Medicaid ID:

Social Security number:

*

Date of birth:

*

"MM/DD/YYYY"

Is this person pregnant?

Yes No      Due Date: *

Click here to add another family member

Below are the family members you have already added

	First Name	MI	Last Name	SSN	Medicaid ID	DOB	Due Date	Suffix

Enter the characters shown below into the box provided before clicking Submit.

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.

HMS, Inc. All Rights Reserved