Health Insurance Enrollment Assistance Inquiry Form for New York City Residents

The NYC Health Department can help you enroll in low- or no-cost health insurance.

Complete this form to receive a call from an enrollment counselor for free assistance in your language, regardless of your immigration status.

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* 1. First Name:

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* 2. Last Name:

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* 3. ZIP Code:

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* 4. Age:

I am 64 or younger

I am 65 or older

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* 5. Disability status:

I am living with a disability

I am visually impaired

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* 6. Type of service:

I would like to enroll in health insurance

I would like to renew my current health insurance

I want information on health insurance only

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* 7. Phone Number (XXX-XXX-XXXX)

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* 8. Best time to reach you:

Morning

Afternoon

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* 9. Preferred language (if other than English):

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* 10. How did you hear about this service?

NYC Health Department Website

Flyer/Poster

Social Media

Word of Mouth

Radio/TV

Other