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.

Please enable JavaScript in your browser to complete this form.

Who are you applying for? *YourselfSomeone Else

Your name, if applying for someone else

Your phone number, if applying for someone else

Relationship to Client? *

Please fill out the client Information below.

First Name *

Last Name *

Email

Phone Number *

Address *

Zip Code *

Would you like to receive future updates and mailings from us? *

• Yes
• No

Date of Birth *

MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Sex at Birth *MaleFemalePrefer not to respond

Sexual Orientation *Straight/HeterosexualBisexualGay/Lesbian/Same-Gender LovingQuestioning/UnsureNot listed, please specifyPrefer not to respond

Please Specify *

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 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 B – Medical InsuranceSupplemental Insurance (Medigap)Prescription Drug PlanMedicare Advantage Plan

What type of help might you need? (Select ALL that apply) *What 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-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:

Have you ever served in the US military? *

• Yes
• No
• Prefer not to respond

In affiliation with someone who is serving or has served in the US military? *

• Yes
• No
• Prefer not to respond

If affiliated, would you like us to share your contact details with VA for additional assistance? *

• Yes
• No
• Prefer not to respond

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

• Information & Awareness (locate resources in Santa Clara County);
• Care Management;
• Caregivers Network;
• Digital Link (iPad Technology Program);
• Meals on Wheels;
• Public Authority Services;
• Senior Employment Services;
• South County Services;
• Other;

Other Services

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

Submit