Health Insurance Counseling & Advocacy Program

Health Insurance Counseling & Advocacy Program (HICAP) services are available to current Medicare beneficiaries living in Santa Clara County; those about to become eligible for benefits; and anyone who wants to learn more about buying health insurance while planning for retirement.

HICAP is part of the national network of State Health Insurance Assistance Program (SHIP) and is the Santa Clara County source for unbiased and objective Medicare-related counseling and information. Please fill out the form to see how you qualify.

Who are you applying for?YourselfSomeone Else

Applying for someone elseFamily MemberFriend / NeighborClient / Patient

How are you related to the person?

• Spouse
• Child
• Grandchild
• Sibling
• Nephew
• Niece
• Cousin
• Friend
• Neighbor
• Client/Patient

Your name, if applying for someone else

Your phone number, if applying for someone else

Please fill out the client Information below.

First Name *

Last Name *

Email

Phone Number *

Address *

Zip Code *

Date of Birth *

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What language do you feel most comfortable speaking? *

• English
• Mandarin
• Vietnamese
• Spanish
• Other

Other Language

What Health Coverage do you currently have? (Select ALL that apply) *Employer Group Health Plan from current employmentEmployer Group Health Plan from current employmentCOBRA Group Health Plan from previous employmentGroup Health Plan due to retirementPlan purchased from Covered CaliforniaMedi-Cal (California’s Medicaid program)Medicare Part A – Hospital InsuranceMedicare Part B – Medical InsuranceMedicare Supplemental Insurance (Medigap)Medicare Prescription Drug PlanMedicare Advantage PlanVeterans AdministrationPrivate non-exchange planUnsureOther

Other type of coverage

Which area(s) of Medicare would you like more information? (Select All that apply) *Part A – Hospital InsurancePart A – Hospital InsurancePart B – Medical InsuranceSupplemental Insurance (Medigap)Prescription Drug PlanMedicare Advantage Plan

What type of help might you need? (Select ALL that apply) *What to enroll inWhat to enroll inWhen to enrollHow to enrollHow Medicare works with my other insuranceHelp with a denial by Medicare, Medicare Advantage or Medicare Prescription Drug PlanHelp with a billOther

Other type of help?

If you need a one-on-one appointment, which would you prefer? *

• In-person
• Telephone
• Virtual
• Not Applicable

For Medicare costs, which would you like to learn about? (Select ALL that apply) *Medi-CalMedi-CalMedicare Savings Programs (MSP)Extra Help with Part D (Low Income Subsidy / LIS)None of the above

For help with Medicare costs please estimate your monthly gross income:

Please check the services below where you would like to receive more information. *

• Information & Awareness (locate resources in Santa Clara County);
• Digital Inclusion (iPad Technology Program);
• Senior Employment Services;
• Caregivers Network;
• Meals on Wheels;
• Care Management;
• Public Authority Services;
• Dignity at Home Fall Prevention;
• Sourcewise Transit Service;
• Other;

Other Services

How did you find out about this program? *Postcard in MailEmail from SourcewiseCase ManagerFriend or Family MemberSocial Media

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