DPS Medicaid Program - Request for Enrollment

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Welcome to the DPS Medicaid Program! Our Outreach and Enrollment Specialists assist families apply and access free or low-cost health insurance. Please submit this form and a Medicaid Specialist will be in touch with you and/or the family.
**Information Provided is Strictly Confidential**

¡Bienvenido al Programa Medicaid de DPS! Nuestros especialistas en divulgación e inscripción ayudan a las familias a solicitar y acceder a un seguro médico gratuito o de bajo costo. Envíe este formulario y un especialista de Medicaid se pondrá en contacto con usted y/o la familia.
**La información proporcionada es estrictamente confidencial**

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