• Apply Online
• Apply by Mail
• Apply by Phone
• Mailing Required Documents

Apply Online

1. Fill out the online application. It's easy, and should take only 10-15 minutes to complete.
2. Electronically sign the application on the "E-Signature" page.
3. Mail in any required documents listed on the "Confirmation" page. Include the "e-form" number shown on the Confirmation page on each of your documents before mailing them.


4. What happens next?

Apply by Mail

1. Download a PDF version of the enrollment application:
• ENGLISH Application Form [PDF, 256KB]
• SPANISH Application Form [PDF, 311KB]
2. Follow the instructions to fill out the application.
3. Mail in your application, along with a copy of the documentation showing you’re eligible.


4. What happens next?

Apply by Phone

1. Call 1-866-717-5826 on Monday - Friday, 8 a.m. to 11 p.m. EST. TTY users call 1-866-561-1604.
2. Mail in a copy of the documentation showing you’re eligible.
3. Eligibility documentation


4. What happens next?

Mailing Required Documents

If your application was submitted online through this webisite, you have 10 days to mail in all of your supporting documents before your application is considered incomplete. Your application will be cancelled 21 days after it is marked incomplete, or by the end of the calendar month, whichever is later. If your application is cancelled for this reason, you may re-apply immediately.

Applications sent by mail without proper documentation are considered incomplete. You’ll get a letter in the mail that explains what information is missing, and gives instructions for mailing the required documents before the application is cancelled.

Please mail all eligibility documentation to the National Finance Center:

• National Finance Center
• Pre-Existing Condition Insurance Plan
• P.O. Box 60017
• New Orleans, LA 70160-0017