Health Insurance Application for Extended Family Planning Benefits ... 2026

1. Click ‘Get Form’ to open the Health Insurance Application for Extended Family Planning Benefits in the editor.
2. Begin by filling in your personal information, including your name, residence, and mailing address if it differs from your home address. Ensure all details are accurate as this will be used for communication regarding your eligibility.
3. Answer questions 1 through 3 regarding your reproductive history and whether you wish to participate in the Family Planning Waiver program. Your responses here are crucial for determining eligibility.
4. List all individuals living in your household in question 4, starting with yourself. Remember, only you need to provide your Social Security Number and proof of citizenship.
5. For question 5, detail the income sources of everyone in your home. Include employer information and any other relevant financial details.
6. Complete questions 6 through 8 regarding health insurance coverage and KidCare enrollment if applicable.
7. Read the Certification and Authorization section carefully before signing and dating the form. This step is essential for processing your application.
8. Finally, submit the completed application to your local health department either by mail or in person.

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