Get help with health insurance!
Complete this form to request help from GHF's Health Insurance Navigators.
Contact Information
First Name
Last Name
Date of Birth
Street Address
(Optional)
Postal Code
City
State/Province
- State -
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
AS
FM
GU
MH
MP
PR
PW
VI
AA
AE
AP
Email
Home Phone
(Optional)
(Optional)
Additional Information
What information or help would you like to receive?
(Optional)
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Information about the health insurance options I qualify for
I have questions about or need help enrolling during Special Enrollment
Help choosing or enrolling in a plan on healthcare.gov
I have questions about or need help with Medicaid
Other
Other
(Optional)
How would you like us to contact you? (Please make sure that we can reach you at the contact information that you entered above.)
(Optional)
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Cell Phone / Home Phone
Text
Email
How did you hear about us?
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Google Search
Facebook
GHF's Website
Community Health Event
St. Vincent de Paul Georgia
Healthcare.gov
From a friend or family member
Georgia Legal Services Program (Georgia Enroll)
Other
How did you hear about us? is required.
Other
(Optional)
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