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0116 Rev 516 Rev2 318 Form
Health Insurance Program (CHIP)
You may qualify for a free or low-cost program even if you earn as much as $94,000 a year (for a
family of 4)
Who can use this
application?
Use this application to apply for anyone in your family
Apply even if you or your child already has health coverage. You could be eligible for lower-cost or
free coverage
If you’re single, you may be able to use a short form. Visit HealthCare.gov
Families that include immigrants can apply. You can apply for your child...
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