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Application Form for Coverage with Financial Assistance for Individuals

Complete the Financial Assistance application for Individuals if you are: single, aged 21-64, have no children or dependents, do not get Medicare and do not have full health insurance coverage from your job. Get the form

You can submit the form in different ways:

  • Create a DC HealthLink account. Go there  to fill out and submit an online application, or
  • Call 1 (855)  532-5465 and submit an application over the phone or
  • Get help from a trained expert by calling 1 (855) 532-5465 or going to the DC Healthlink website.

Print out the Application Form for Coverage with Financial Assistance for Individuals    

Mail the application to:         

DC Health Link
Department of Human Services
Case Record Management Unit
P.O. Box 91560
Washington, DC 20090

Or Fax it to:  (202) 671-4400

Or come in person to any ESA Service Center