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How to Get an Application?
You can obtain an application by clicking one of the links below or you may call us to request an application at 1-877-428-5060, Monday - Friday, 8 a.m. to 8 p.m. and Saturday, 8 a.m. to 5 p.m. The call is free.
- PCIP/ MRMIP Application (PDF 139kb):
The PCIP/MRMIP Application includes a checklist of important steps for completing the application. - See or print the PCIP/MRMIP Handbook (PDF 1,550kb):
The PCIP/MRMIP Handbook includes the four-page PCIP/MRMIP Application. Open an Acrobat version of the handbook. - Call 1-877-428-5060 and ask for the PCIP/MRMIP Application.
When you apply for the PCIP and/or MRMIP, your application will be reviewed for both health care programs to inform you of your coverage options. In order for your eligibility to be determined for both programs, you need to fill out the PCIP/MRMIP Application. If you qualify for both programs, we will enroll you in the program that you prefer in question #2. If you do not select a program, we will enroll you in PCIP.
PCIP Forms
- Change of Address Form (PDF 54kb)
- Electronic Funds Transfer Form (PDF 150kb)
- Permission to Share PCIP Information (PDF 58kb)
- Appeal Form (PDF 189kb)
- Provider Form (PDF 24kb)
- Provider Sample Letter (PDF 22kb)