If you live in the Eastern Region, including in Atlanta, Chicago, Minneapolis, Nashville, New Orleans and New York City, choose AHIRC Eastern.
If you live in California, choose EHIS.
If you live in the Western Region, including Dallas, Houston, Las Vegas, Portland, and Seattle, choose AHIRC Western
If you have previously submitted a request for assistance through Submittable please use the Change of Information/Update form. This form is for those returning for assistance with insurance enrollment/renewal, a change in circumstances like change of household, income, and insurance status, or a new issue that has affected you or your household members.
If you live in AL, AR, CT, DE, FL, GA, IA, IL, IN, KY, LA, MA, ME, MD, MI, MN, MO, MS, NC, OH, NH, NY, NJ, PA, RI, SC, TN, VA, VT, WI, WV, and Washington DC, please use this form.
If you live in AK, AZ, CO, HI, ID, KS, MT, ND, NE, NM, NV, OK, OR, SD, TX, UT, WA, WY, please use this form. If you live in California, please click on the form below
If you live in California, please use this form
Use this form if you’ve previously submitted a request for assistance through Submittable. This form is for those returning for assistance with insurance enrollment/renewal, a change in circumstances like change of household, income, and insurance status, or a new issue that has affected you or your household members.