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Health Care Programs Application (includes Catamount Health with Premium Assistance)

Complete this application for:

• Catamount Health with Premium Assistance (CHAP)
• Employer-Sponsored Insurance with Premium Assistance (ESIA)
• Vermont Health Access Plan (VHAP)
• Dr. Dynasaur
• Prescription Assistance
  • Includes VHAP-Pharmacy, VScript, VPharm and Healthy Vermonters.
  • If you are only applying for Prescription Assistance, please instead use the "Pharmacy Programs Application."

You may print this application, or save it to your desktop, before filling it out.  However, you must sign page 7 and mail your completed application to the address provided on page 7.

Catamount Health Application (for applicants NOT applying for Premium Assistance)

Complete this application for:

• Catamount Health (Full-Pay)
  • If you believe you qualify for Premium Assistance, please complete the "Health Care Programs Application."

Application for Health Care Assistance

Complete this application for:

• Medicaid
  • Although this application can also be used to apply for Catamount Health Premium Assistance, Vermont Health Access Plan (VHAP), Dr. Dynasaur and/or Prescription Assistance, it requires more detailed information than necessary.

Pharmacy Programs Application

Complete this application for:

• Prescription Assistance
  • This application is only for Prescription Assistance programs including VHAP-Pharmacy, VScript, VPharm and Healthy Vermonters.

For information or assistance at any time, call Green Mountain Care at 1-800-250-8427.