Get an Application

Am I eligible for the HealthyCare Card?

If you are uninsured and eligible for health insurance, you should pursue these options before submitting this application: Health insurance from your employer, or spouse’s employer, Medicare, the State Exchanges, Medical Assistance.  Even with commercial health insurance you may still be eligible for financial assistance.  Eligibility is based on household income and assets.

If you have questions, please contact us and we will help guide you.

Not sure when your card expires?

The expiration date is located on the bottom right corner of your card.   


Download the HealthyCare Card application – English Version - PDF

One Person Application(5 pages)

Two Person application (6 pages)

Click here for each additional person applying
(2 additional pages)

Descargue la aplicación HealthyCare Card

–Versión en Español - PDF

Aplicación para una persona (5 páginas)

Aplicación para dos personas (6 páginas)

Haga clic aquí para cada persona adicional aplicando
(2 páginas adicionales)


After completing the application, please send it with the required documents to:


By mail-
Healthy Community Network
116 South George Street, Suite 101
York, PA  17401

By fax- (717)848-2029

or email-