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Family Health Insurance Assistance Program
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Reserve A FHIAP Application
Reserve A FHIAP Application
The Family Health Insurance Assistance Program, or FHIAP, helps thousands of Oregon families pay the monthly premium for high-quality, private health insurance plans.
 
If you complete this form, a FHIAP group or individual application will be mailed to you as funds allow. You will be placed on our reservation list until that time. If you want more information about the program, please call toll-free in Oregon 1-888-564-9669. Our customer service staff will explain FHIAP. You may also visit our Web site at www.fhiap.oregon.gov.
Reservation Form
Contact information:
First name:
Middle initial:
Last name:
Day phone:
E-mail address:
Mailing information:
Mailing address:
City:
State:
 Must be an Oregon resident.
ZIP:
Family information:
How many adults are in your family?
How many children are in your family?
Is any member of your family enrolled in the Oregon Health Plan (OHP)? Yes    No
Have you or any member of your family been uninsured for 6 months? Yes   No
Heritage:
(For statistical purposes only)
Employment information:
Are you or your spouse employed? Yes    No      OR
Are you or your spouse self-employed? Yes        No
If yes, please complete the following:
Employer's name or self-employed name:
Does your or your spouse's employer offer health insurance?
No      Employee only       Entire family
Is it available now? Yes    No
Is your spouse employed?
Not married    Yes    No
Spouse's employer's name:
Other information:
How did you hear about FHIAP?
Are you working with an insurance agent? Yes     No
If yes, please list:
Agent's name:
Agent's license no.:
If you press “submit,” your name will be added to the list of people who want a FHIAP application. We will then send a letter to confirm your request for an application.

If you do not receive a letter from FHIAP within two weeks, please call: 1-888-564-9669. Our customer service staff will help you.

                 

Technical Assistance
If you have questions, comments, or problems relating to the technical aspects of this site, please e-mail Rosie Baker.
 
Page updated: October 22, 2009

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