Get Help Now!

Call 412-456-1877 ext 200 for immediate assistance.

If you are over 65 and want to apply for PACE, a Pennsylvania-sponsored prescription drug benefit program that subsidizes medications, visit their website for instructions and enrollment forms.

Consumer Health Coalition Intake Form

You can use this form to send us your biographical information electronically, so that we can better help you.

First Name
Last Name
Address
City
State
Zip
County
Phone Number
Work Number
Email
Date of Birth
Marital Status
Household Size
Does anyone in the household have a disability or an illness?

If yes, please describe

Is anyone in the household pregnant?

If yes, anticipated due date

Have you been a resident of PA for 90 days?
Do you have health insurance?

If no, did any adult you are applying for, have health insurance in the last 90 days

Does anyone in the household receive SSI or SSDI?

If yes, how much do you receive

What is the average monthly income for the household?
Do you need help for anyone else in your family?

List the names, social security numbers, and dates of birth for the family members who need help

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Consumer Health Coalition Intake Form