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COUNTY OF LOS ANGELES DEPART ENT OF HEALTH SERVICES MY HEALTH LA (HLA) CONTRACTUAL CHANGE REQUEST Date:Agreement No. Agency Name: Contact Name:Phone#:ACTION REQUESTED Adding a New and/or Transferring

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How to fill out county-based health coverage for

01

Obtain the necessary application form for county-based health coverage

02

Fill out all required personal information such as name, address, contact details, and social security number

03

Provide information about your household members including spouse, children, and any dependents

04

Declare your income and provide documentation such as pay stubs or tax returns

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Submit the completed application either online, by mail, or in person at the county health department

Who needs county-based health coverage for?

01

Individuals who are residents of a specific county and meet the income eligibility criteria

02

People who do not have access to employer-sponsored health insurance or Medicaid

03

Families with children who qualify for state or federal health coverage programs

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What is county-based health coverage for?

County-based health coverage is for providing healthcare services to residents of a specific county.

Who is required to file county-based health coverage for?

Residents of the county who qualify for the coverage are required to file for county-based health coverage.

How to fill out county-based health coverage for?

County-based health coverage can be filled out online or through a paper application provided by the county health department.

What is the purpose of county-based health coverage for?

The purpose of county-based health coverage is to ensure that residents have access to necessary healthcare services.

What information must be reported on county-based health coverage for?

Information such as personal details, income, household size, and any existing healthcare coverage must be reported on county-based health coverage forms.

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