Health Care Coverage
This application may be used by families with children who apply
for health care benefits under the Children’s Health Insurance
Program (CHIP) or the Medical Assistance Program.
Health Care in Pennsylvania.
Easy, affordable protection for your family.
Commonwealth of Pennsylvania, Edward G. Rendell, Governor
Information about Health Care Coverage
Please note: If you need Medical Assistance benefits for families without
children, cash assistance or food stamps, you must complete a different application.
Please call your County Assistance Office and they will send you the proper form.
If you need help with this form: Call the Helpline at 1-800-986-KIDS. If you are
hearing impaired, call TTY 1-877-232-7640.
Si necesita este información en español, llame al teléfono: 1-800-986-5437.
• Sick visits and prescription drugs
• Emergency room care
• Hearing testing and hearing aides
• Dental care
• Vision testing and eyeglasses
• Lab tests and X-rays
• Mental health and substance abuse
• Durable medical equipment
• Hospital care
Health Care Coverage May Include:
Questions You May Have:
Q: Which program can my children enroll in?
A: Whether your children are enrolled in CHIP (Children’s Health Insurance Program) or
Medical Assistance will depend mostly on your household income and the ages of your
children. You may apply to the program of your choice, however, your family circum-
stance will determine what program your children will be eligible for. This application
will work for either program. It is not necessary to fill out this application twice.
• If you apply first to Medical Assistance but are not eligible, your application will be
sent to a CHIP contractor to see if you are eligible.
• If you apply first to CHIP but are not eligible, your application will be sent to the
County Assistance Office to see if you are eligible for Medica