Application for Health Coverage & Help Paying Costs
(DHS-1100)

Need help with your application? Visit mybenefits.hawaii.gov or call 1-877-628-5076. If you need help in a language other than English, call 1-877-628-5076 and tell the customer service representative the language you need. TTY users should call 1-877-628-5076.

Step 1 of 6.

Tell us about yourself

(We need one adult in the family to be the contact person for your application.)

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    1. -
  2. ()- ext:
  3. ()- ext:
  4. Info by Email
  5. Family Member Incarcerated
  6. Parent living outside of home

    If yes, I understand I will be asked to cooperate with the Department of Human Services and the agency that collects medical support from an absent parent. If I think that cooperating to collect medical support will harm me or my children, I can tell Medicaid and I may not have to cooperate.

Thursday, December 13, 2018