Online Application for WV HIPP - West Virginia's Health Insurance Premium Payment Program Fill out this form. Then click Submit to send it to us.

Apply Now

*These are required fields. Make sure you fill in these boxes.

Step 1. How did you hear about WV 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. 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 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. 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 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

(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 VisitsMedicineHospital 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 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.

If you would like to receive your payment by direct deposit, please download our WV HIPP Direct Deposit form and return it to us within 10 days of your application submission.

Please call us at 1-855-MyWVHIPP(1-855-699-8447) or send email to CustomerService@MyWVHIPP.com if you experience problems with this form.

No time to fill out online? Download a West Virginia HIPP Application to fax or mail to us.

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