Mission GED Application

AmeriHealth Caritas Delaware's program to help you get your high school equivalency diploma.
Complete this form to take the first steps toward your future. You may also get this form on our website at www.amerihealthcaritasde.com/GED or by calling our Rapid Response and Outreach Team at 1-844-623-7090 (DSHP TTY: 1-855-349-6281 or DSHP-Plus TTY: 1-855-362-5769) to request a form by mail.
To participate you must:
- Be a current AmeriHealth Caritas Delaware member.
- Be 18 years or older.
- Not have a high school diploma or equivalent.
- Not be currently enrolled in high school or college.
Are you a current member of AmeriHealth Caritas Delaware?
AmeriHealth Caritas Delaware ID#:
Example: 00-0000000
Name:

First NameLast Name
Gender
Street address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email address:
example@example.com
Age:
Date of birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone number:
Format: (000) 000-0000.
Race or ethnicity:
Primary language spoken:
What is the last grade of school you completed?
Are you in school now?
Have you ever attended an adult education program (GED program)? If so, where?
Are you currently attending a GED program? If so, where?
Applicant signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
This completed form will be sent directly to our Rapid Response and Outreach Team: 1-844-623-7090 (DSHP TTY: 1-855-349-6281 or DSHP-Plus TTY: 1-855-362-5769)

Someone from the team will contact you in 3-5 business days.

AmeriHealth Caritas Delaware complies with applicable federal civil rights laws and does not discriminate on the basis of race; ethnicity; color; sex; religion; national origin; creed; marital status; age; Vietnam era or disabled veteran status; income level; gender identity; the presence of any sensory, mental, or physical handicap; or any other status protected by federal or state law.
You can have this information in other languages and formats, such as large print, Braille, and audio at no charge to you. You can also have this interpreted over the phone in any language. To request language services or other formats, call Member Services 24 hours a day, 7 days a week, at 1-844-211-0966 (DSHP) or 1-855-777-6617 (DSHP-Plus). For TTY, call 1-855-349-6281 (DSHP) or 1-855-362-5769 (DSHP-Plus). For pharmacy services, call 1-877-759-6257 (DSHP) or 1-855-294-7048 (DSHP-Plus). To speak to a nurse 24/7, call 1-844-897-5021.
Puede solicitar esta información en otros idiomas y formatos, como letra grande, Braille y audio, sin costo alguno para usted. También se le puede interpretar esto por teléfono en cualquier idioma. Para solicitar servicios de idiomas u otros formatos, llame a Servicios al Miembro las 24 horas del día, los 7 días de la semana, al 1-844-211-0966 (DSHP) o 1-855-777-6617 (DSHP-Plus). Para personas que usan TTY, llame al 1-855-349-6281 (DSHP) o 1-855-362-5769 (DSHP-Plus). Para servicios de farmacia, llame al 1-877-759-6257 (DSHP) o 1-855-294-7048 (DSHP-Plus). Para hablar con un enfermero las 24/7, llame al 1-844-897-5021.
您可以免费索取这些信息的其他语言版本及大字印刷、盲文点字、音频等其他格式。您亦可以要求通过电话口译的方式将这些内容翻译为任何语言。如需语言服务或其他格式,请拨打会员服务部每周7天、每天24小时全天候提供服务的电话1-844-211-0966 (DSHP)或1-855-777-6617 (DSHP-Plus)。TTY 使用者请拨打1-855-349-6281 (DSHP)或1-855-362-5769 (DSHP-Plus)。如需药房服务,请拨打1-877-759-6257 (DSHP)或1-855-294-7048 (DSHP-Plus)。如需每周7天、每天24小时随时与护士交谈,请拨打1-1-844-897-5021。
www.amerihealthcaritasde.com
AmeriHealth Caritas
Delaware
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AmeriHealth Caritas Delaware's program to help you get your high school equivalency diploma.