Written by a parent, not a doctor. Nothing here is medical advice.

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California Department of Health Care Services

Health Insurance Premium Payment Program

What you get

Help paying private health-insurance premiums when the plan meets the cost rules. Ask whether requests are open.

Who starts it
You, with a document from your doctor
How it’s sent
By post
Your time
About 30 minutes, plus waiting for the document
Last checked
Aug 27, 2026

  1. Ask your doctor for the documentStart here. This is the part that takes the longest.

    California Department of Health Care Services needs a signed confirmation of the diagnosis from your doctor. It has to cover one thing. Copy this message, or say it in person at the next visit.

    Hi [doctor’s name],

We’d like to apply to California Department of Health Care Services’s Health Insurance Premium Payment Program. Help paying private health-insurance premiums when the plan meets the cost rules. We are checking whether they are taking requests.

They need a signed confirmation of the diagnosis from you. It has to cover current medically confirmed diagnosis. Their form and instructions are here: https://www.dhcs.ca.gov/services/Pages/default.aspx

Could you do that when you have a chance? I’ll bring the printed form to our next visit, or I can email it. Thank you for everything you do for us.

[your name] · [phone]
    Copying is the only thing this page does with your text. Nothing is saved.

  2. Fill in their formPrint it, or fill it in on screen if the PDF allows.

    Open the application PDF ↗ Checked Aug 27, 2026

    What the form asks for

    DHCS 6172 HIPP Application
    1. Name of Applicant2. Social Security Number3. Telephone Number4. Applicant’s Home Address, City, State, ZIP Code5. Name of Insurance Carrier6. Policy Start Date7. Premium Billing Address (where premiums are mailed), City, State, ZIP Code8. Policy Number9. Total Monthly Premium10. Total Number of People Covered under Policy11. Name of Policyholder12. Policyholder’s Social Security Number13. Is the applicant enrolled in Medi-Cal14. Is the applicant enrolled in a Medi-Cal Managed Care Plan15. Is the policyholder court ordered to provide the medical insurance16. Is the applicant enrolled in Medicare17. Is the policyholder fully reimbursed for payment of health care premiums18. If in Medi-Cal, has the applicant maintained the same insurance policy since they were first enrolled in Medi-Cal19. Signature of Applicant (or Authorized Representative) and Date

    Have ready

    • Completed DHCS 6172 HIPP Application.
    • Required HIPP Disclosure Statement, read and signed by the applicant/guardian and policyholder.
    • Required HIPP Release of Information.
    • Policy booklet or Evidence of Coverage from the individual or group health insurance carrier.
    • Required Payee Data Record (STD 204);.
    • Notice to Terminating Employees form listed in the required HIPP forms packet.

  3. Post your application and the document togetherTo the address on the form.

    • Mail the complete packet to Department of Health Care Services, HIPP Program, MS 4719, PO Box 997425, Sacramento, CA 95899-7422.

After you send

HIPP states that new applications are processed within 30 days after all required documentation is received; contact HIPP if receipt or missing items are unclear. If you have not heard back by then, write and ask.

Full record, as published