Health Insurance Help
Contact Information
First Name
Last Name
Phone Number
Email Address
Preferred Contact Method
Phone
Text
Email
Our team is available Monday through Friday, 9:30 AM–6:30 PM.
Preferred Day to Contact
Please select...
Monday
Tuesday
Wednesday
Thursday
Friday
No Preference
Best Time to Contact
Please select...
Anytime during business hours
9:30 AM – 11:30 AM
11:30 AM – 1:30 PM
1:30 PM – 3:30 PM
3:30 PM – 5:00 PM
5:00 PM – 6:30 PM
Please contact me by email
Are you completing this form for yourself?
Yes
No
Person You Are Assisting
Name of the person you're assisting
Your relationship to this person
Please select...
Parent/Guardian
Spouse/Partner
Family Member
Friend
Caregiver
Case Manager/Social Worker
Community Partner
Other
Get Help Intake
Location
ZIP Code
County
Please select...
Fulton
Barrow
Bartow
Butts
Carroll
Cherokee
Clayton
Cobb
Coweta
Dawson
DeKalb
Douglas
Fayette
Forsyth
Gwinnett
Haralson
Heard
Henry
Jasper
Lamar
Lumpkin
Newton
Meriwether
Morgan
Paulding
Pickens
Rockdale
Spalding
Walton
Health Coverage
Do you currently have health insurance?
Yes
No
Not Sure
What is you insurance company or plan name?
When was the last time you had health coverage?
Please select...
I currently have coverage
Within the last 30 days
1–3 months ago
4–6 months ago
7–12 months ago
More than a year ago
I have never had health insurance
Not sure
About how much could you comfortably pay each month for health insurance?
Please select...
Choice A
Choice B
Choice C
$0 / I need a no-cost option
Under $25
$25–$50
$51–$100
$101–$200
More than $200
I’m not sure
This does not determine what your insurance will cost. We’ll help you see what coverage and savings you may qualify for.
What do you need help with?
Please select...
I need health insurance
I need help applying for Georgia Access
I need help choosing/enrolling in a health plan
I lost my health insurance
I need help renewing my coverage
I need to make a change to my coverage
I need dental coverage
I am not sure what I need
Other
Tell us anything else you would like us to know.
Submitting this form does not enroll you in health insurance. A POWER Atlanta Certified Application Counselor will contact you to help with your next steps.