Eligibility Form
Person with curly hair in pink button down shirt against orange background.

Find Out If You Qualify for SelectHealth

To find out if you qualify to enroll in SelectHealth specialized Medicaid plan, please fill out the following form, and one of our representatives will contact you. As always, we respect your privacy and will not share your information.

Questions? Call us at 1-866-469-7774 (TTY: 771).

Please fill out the
following form
and one of our
representatives
will contact you.

Questions?
Call us at
1-866-469-7774
(TTY: 711)
8 am — 6 pm
Monday – Friday.

As always, we respect your privacy and will not share your information.

  • Please note: The starred fields ( * ) are required information.
  • The SelectHealth representative will only identify themselves by their first name and will NOT mention that they are from SelectHealth.
  • This field is for validation purposes and should be left unchanged.
Thank you!

A member of the SelectHealth team will be in touch with you shortly.