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Programs & Services: WA Medical for Kids

Click to download the CHIP application form for medical coverage only for children and teens under 19.

Our electronic forms are meant to be filled out online and sent to us using the embedded e-mail button. Please e-mail to achd@co.asotin.wa.us

Forms may also be printed, faxed, mailed or dropped off in person. Web-based e-mail (e.g. hotmail, yahoo, gmail) May not work properly with the embedded E-mail button.

Our forms use Adobe Acrobat. Click the button to download a Acrobat Reader for free.

printlogo Are Your children Eligible for

WA State Medical Insurance?

Family size	THESE INCOME LEVELS QUALIFY FOR: Free health insurance		THESE INCOME LEVELS QUALIFY FOR: $ 20 monthly premium per child. No family pays more than $40.		THESE INCOME LEVELS QUALIFY FOR: $ 30 monthly premium per child. No family pays more than $60.
	Monthly income	Annual income	Monthly income	Annual income	Monthly income	Annual income
1	Up to $1,805	Up to $21,660	Up to $2,257	Up to $27,075	Up to $2,708	Up to $32,490
2	Up to $2,429	Up to $29,140	Up to $3,036	Up to $36,425	Up to $3,643	Up to $43,710
3	Up to $3,052	Up to $36,620	Up to $3,815	Up to $45,775	Up to $4,578	Up to $54,930
4	Up to $3,675	Up to $44,100	Up to $4,594	Up to $55,125	Up to $5,513	Up to $66,150
5	Up to $4,299	Up to $51,580	Up to $5,373	Up to $64,475	Up to $6,448	Up to $77,370
6 or more	Add $624 for each additional child	Add $7,480 for each additional child	Add $780 for each additional child	Add $9,350 for each additional child	Add $935 for each additional child	Add $11,220 for each additional child

Premiums are based on the number of children in a family but no family pays more than two premiums a month.
Children must be under the age of 19.
Pregnancy counts as an additional person.

APPLICATIONS AVAILABLE AT

ASOTIN COUNTY HELTH DISTRICT

431 ELM STREET

CLARKSTON, WA 99403

509-758-3344

www.applehealthforkids.wa.gov