Appointment Request Form
To schedule an appointment, please fill out this form to see if you might qualify for CoveredCA and also subsidy
Appointment Location
*
Please Select
Chula Vista - San Diego, CA
Oceanside - San Diego, CA
Vista - San Diego, CA
Escondido - San Diego, CA
San Fernando - Los Angles, CA
Full Name
*
First Name
Last Name
Contact Number
*
Please enter a valid phone number.
Email Address
example@example.com
What date and time work best for you?
*
Household Size
*
Please Select
1
2
3
4
5
6
7+
Household Income
*
Please Select
$20,000 - $30,000
$30,000 - $40,000
$40,000 - $50,000
$50,000 - $60,000
$60,000 - $70,000
$70,000 - $80,000
$80,000+
Submit
Should be Empty: