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?*
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:
  
Social Security number:
*
Date of birth:
*
"MM/DD/YYYY"
Address:
*
Apartment/Lot #:
  
City:
*
State
*
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
  
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

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
  
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.

2p134v




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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