Online Application for AR HIPP -
Arkansas's Health Insurance Premium Payment Program
Fill out this form. Then click Submit to send it to us.
Apply Now
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These are required fields. Make sure you fill in these boxes.
Step 1. How did you hear about AR HIPP?
*
Please Select
Program information mailed to my home
My Medicaid caseworker gave me program information
A search engine helped me find online information about the program
I found program information while on a social network or blog
I read about the program in a Medicaid newsletter or publication
A health related support group gave me program information
My doctor's office gave me program information
My employer or human resources gave me program information
My child's school gave me program information
An employee benefits fair gave me program information
I saw an outdoor program advertisement
A friend told me about the program
Step 2. Tell us about the person in your family who can get health insurance at work (or another place).
First name:
*
MI:
Last name:
*
Suffix:
Please Select
Jr
Sr
II
III
IV
V
VI
VII
VIII
IX
Social Security number:
*
Date of birth:
*
"MM/DD/YYYY"
Address:
*
Apartment/Lot #:
City:
*
State
*
Please Select
ALABAMA
ALASKA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FLORIDA
GEORGIA
GUAM
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
Zip:
*
-
Best phone number to call:
*
Email
Step 3. Tell us about the health insurance or COBRA benefits the person in Step 2 can get.
(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 Select
ALABAMA
ALASKA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FLORIDA
GEORGIA
GUAM
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
Zip:
-
Health plan name:
Policy ID number
Group number:
Policy start date:
"MM/DD/YYYY"
Monthly insurance premium
(We only need this if you already get insurance.)
Is this COBRA insurance?
Yes
No
COBRA Start Date:
*
COBRA End Date:
Check the box next to the items your insurance covers:
Doctor Visits
Medicine
Hospital Stays
Step 4. Tell us about the employer or other place that offers the health insurance or COBRA.
Employer or company name:
Address:
City:
State
Please Select
ALABAMA
ALASKA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FLORIDA
GEORGIA
GUAM
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
Zip:
-
Phone:
Step 5. Tell us about the family members who get Medicaid.
First name:
*
MI:
Last name:
*
Suffix:
Please Select
Jr
Sr
II
III
IV
V
VI
VII
VIII
IX
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.
If you would like to receive your payment by direct deposit, please download our
AR HIPP Direct Deposit
form and return it to us within 10 days of your application submission.
Please call us at 1-855-MyARHIPP (1-855-692-7447) or send email to
CustomerService@MyARHIPP.com
if you experience problems with this form.
No time to fill out online?
Download the Arkansas HIPP Application
to fax or mail to us.
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