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April 7, 2003

 
 

 

From the San Francisco Health Plan

 

 
LOW-COST HEALTH CARE COVERAGE

FOR YOUR CHILD!

 

 

If your child does not have health, dental, or vision coverage,

complete this form and email it to Mario Moreno at mmoreno@sfhp.org.

We will help enroll your child in a health insurance program that is right for them.

     

 

 Yes!  Id like more information on low-cost health care coverage

          Id like to set up an appointment to apply for health care coverage

               Please have someone from a community organization or health plan call to help me apply.

     I understand that all help is free of charge.   All information is confidential.

 

     

    Parent/Guardians Last Name ______________________ First Name___________________

 

    Address_________________________________________________ Zip______________

 

    Phone # __________________________ Message Phone #  _________________________

    When is the best time to call you? __________ (am) __________ (pm) 

    Name of school ______________________________________

    The language I speak best is (English, Cantonese, Spanish, etc) _________________________

           

IMPORTANT:  Even if your child was not born in the U.S. or if you earn too much to qualify for other health care coverage programs your child may be eligible for low-cost medical, dental, and vision care through the Healthy Kids program. 

For More Information CALL (415) 777-9992