Application Form and Instructions for HUSKY
The first step to getting HUSKY health coverage is to send us an application. After downloading the HUSKY Application Form, please complete it and mail to the address on the form.
There is no cost or obligation when you apply.
If you need help filling out the application – or if you want to begin the application by phone with a customer service representative:
Call 1-800-656-6684
Hours:
9:00 am - 8:00 pm Monday through Thursday
9:00 am - 6:00 pm Friday
10:00 am - 2:00 pm Saturday
TDD/TTY line for persons with hearing impairment, 1-800-842-4524. Auxiliary aids are also available for persons with visual impairment or other disabilities.
Note: The application file, along with other relevant forms and brochures, are available in Adobe Acrobat format to download. The Acrobat PDF format makes the application very easy to print and and fill out off-line. If you don't have the Adobe Acrobat reader,
you can download it here for FREE
For visually challenged users, Adobe provides an Acrobat Plug-in for interpreting documents written in pdf format. Follow the links below to get the Plug-in:
Citizenship
United States citizens (including naturalized citizens and nationals of the United States) are required by federal law to prove citizenship identity to be eligible for HUSKY A (Medicaid) coverage. You will be asked to prove citizenship and identity AFTER you send in your HUSKY application form.
The following brochure will give you further information.
Enrollment Form - Choosing a Health Plan
The form below is for choosing a health plan. You will be mailed a form after you have been approved for HUSKY, so unless you have lost your original form, there is no need to print this out.
