If you are 65 and older and in need of health insurance, the Dept of Human Services can help...

• If you reside in Monroe County, call 585.753.6960
• If you reside in Livingston County, call 585.243.7300

Call 585.613.7662 for a Facilitated Enroller near you

Forms

Requested Forms

Once you have spoken with a facilitated enroller and have scheduled an appointment, you will need to provide certain information.

The following forms are available to help assist you with providing the correct information and assuring you will be well prepared for your appointment.

• Employer Verification of Income - Can be used if you have no other way to verify your weekly, biweekly, or monthly income. Your employer must complete the form, documenting the last 4 weeks of income, making sure the form is completely filled out.
• Child Support - To be completed by the person you are receiving child support from,
• 3-month Financial Status - For documenting self-employment income. Complete this form if you have recently started a business or your last year's income tax return does not reflect your current financial situation.
• Address/Support Verification - When living with a friend, relative, or family member, and they are supporting you, please have that individual complete this form.
• Child Care - Day care provider must complete.
• Employer Sponsored Health Insurance - Your employer must complete this form if you appear eligible for Family Health Plus and are currently enrolled in or have access to employer-based health insurance.

* Make sure you print and completely fill out the forms you will need and bring them to your appointment.