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Washington Health New Application Request
Tell us where to send you the Washington Health application:
All fields are required
First Name:
Last Name:
Mailing Address:
City:
State:
Zip Code:
Choose one:
English Application Packet Covers 1 Individual
English Application Packet Covers 2 Individuals
English Application Packet Covers 3 Individuals
English Application Packet Covers 4 Individuals
English Application Packet Covers 5 Individuals
English Application Packet Covers 6 Individuals
English Application Packet Covers 7 Individuals
Spanish Application Packet Covers 1 Individual
Spanish Application Packet Covers 2 Individuals
Spanish Application Packet Covers 3 Individuals
Spanish Application Packet Covers 4 Individuals
Spanish Application Packet Covers 5 Individuals
Spanish Application Packet Covers 6 Individuals
Spanish Application Packet Covers 7 Individuals
*If you need an application packet to cover more than 7 individuals, please call Washington Health at 1-800-660-9840