Health Insurance Enrollment Specialists at SDSU!
Please complete this form to begin the process of connecting with an Enrollment Specialist about health insurance (Medi-Cal or Covered California Marketplace).


Please look out for a phone call or email. Make sure your voicemail is set up and not full.

THIS IS FOR APPLYING FOR HEALTH INSURANCE ONLY! IF YOU ARE REQUESTING ASSISTANCE WITH UNDERSTANDING YOUR CURRENT HEALTH INSURANCE PLEASE GO HERE:  

https://docs.google.com/forms/d/e/1FAIpQLSeM9gDj6m9q1nN1sDhk4amhrLBtaHavN-YP0pFhUi6EMaMNpQ/viewform
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Email *
 Parent / Guardian's first and last name (if this form is filled out on behalf of a student)
Student's First and Last Name *
Which SDSU campus are you enrolled? *
What class standing are you? *
Best phone number to contact (Please look out for a phone call. Make sure your voicemail is set up and not full) *
Are you or your student currently living in San Diego county? (Our enrollment specialist are only able to assist those currently living in San Diego county) *
If you are NOT currently living in San Diego county, please provide the county and state where you are currently living (Put N/A if you or the student you are requesting for live in San Diego).
Do you want to enroll in calfresh?
This form is for health insurance enrollment only.

You don't need to fill out this form if you just want Cal-Fresh food assistance.

If you will like to request to receive a call to discuss and enroll in Calfresh, please copy / paste and go the following link in separate tab.

https://docs.google.com/forms/d/e/1FAIpQLSde1GD6DDa6NfjEGvsZkiUl49iv9Qbr5Ot1SpSvVpfsuG72SQ/viewform

An enrollment specialist will reach out to you with 24 business hours!
Are you currently enrolled in a health insurance plan? *
If you are currently are enrolled in health insurance, what is the name of the plan?
Which option you do want assistance with? *
Would you like assistance applying for health coverage? *
Are you (the student) in need of serious or sudden medical treatment? *
Tax filling status *
Including yourself, how many people are in your tax household? (exp: If you are the only person please put 1) (This is the taxpayer(s) and any individuals who are claimed as dependents on one federal income tax return. A tax household may include a spouse and/or dependents). *
Current Monthly Gross Income (On average, how much do make monthly before taxes are taken -it would be located on a check stub) If you are not making any income please put 0. If you don't put anything this may delay or prolong your ability to enroll. *
What, if any, other information that is important for us to know?
Please look out for a phone call or email. Make sure your voicemail is set up and not full.
Due to the high volume of people who need assistance we are only able to call you once. Please look out for a phone call. We will only leave a message if your voicemail will allow us to do so.

THIS IS FOR APPLYING FOR HEALTH INSURANCE ONLY! IF YOU ARE REQUESTING ASSISTANCE WITH UNDERSTANDING YOUR CURRENT HEALTH INSURANCE PLEASE GO HERE:

https://docs.google.com/forms/d/e/1FAIpQLSeM9gDj6m9q1nN1sDhk4amhrLBtaHavN-YP0pFhUi6EMaMNpQ/viewform
A copy of your responses will be emailed to the address you provided.
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