FHASES FHASES
Patient Application
  • Must be a resident of Pierce County for at least three months.
  • Must be at or below 300% of the Federal Poverty Level
    $38,640/year for a single person total household income.
  • Must not have? medical insurance.
  • No citizenship requirement.
  • Must be a resident of Pierce County for at least three months.
  • Must be eligible to purchase insurance on the Washington Health Benefit Exchange?.
  • Must file taxes each year, including years prior to current
    $64,400/year for a single person total household income.
  • Cannot be offered other affordable health insurance(Medicaid, Medicare, VA, Tricare, or employer insurance) that costs less than 10% of the total household income.
  • Must be willing to enter into a relationship with PCPA and update income and household information to us throughout the policy year?.


First Name
Middle Name
Last Name
Birth Date
Gender


Address Line 1
Address Line 2
City
State
Zip Code

Mobile Phone
Home Phone
Work Phone
Email Address

Ethnicity
Latino Identity
Preferred Language
Housing Type
Household Size
Household Income (total annual)
Marital Status
Residency Date
Health Insurance
Do you file taxes?

Program
Request
Reason

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