Health Coverage Analysis

If you complete this form and submit it, Cover the Uninsured Month and the S.W. Ohio Covering Kids and Families Coalition can tell you whether you are likely to qualify for some kind of free health or low cost public health coverage.  We will get back in touch with you to let you know and we can help you apply if it appears that you are eligible. Fields marked in red are required.

Your Name




Contact Information

How many children in household?

Health Coverage Analysis

Is anyone in your household pregnant?

Does anyone in your household have a medical condition that prevents them from working full time?

Does anyone in your household have any medical coverage now?

Does anyone in your household have outstanding medical bills?

If yes, list outstanding medical bills.
Household Member Medical Provider Date of Service Amount of Bill
Where did you find out about this website?

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