North Carolina's Health Insurance Premium Payment Program
Fill out this form. Then click Submit to send it to us.

* These are required fields. Make sure you fill in these boxes.

Step 1. How did you hear about NC HIPP? *

Step 2. Tell us about the person in your family who can get health insurance at work (or another place).

First name:* MI: Last name:*    Suffix:
Social Security number:* Date of birth:* "MM/DD/YYYY"
Address:* Apartment/Lot #: City:*
State:* Zip:* - Best phone number to call:*

Step 3. Tell us about the health insurance or COBRA benefits the person in Step 2 can get.
(COBRA is a type of health insurance you can get if you leave a job where you had a health plan.)

Health insurance company name: Insurance company address: City:
State: Zip: - Health plan name:
Policy ID number: Group number: Policy start date: "MM/DD/YYYY"
Monthly insurance premium: (We only need this if you already get insurance.)

Is this COBRA insurance?    

Check the box next to the items your insurance covers:

Step 4. Tell us about the employer or other place that offers the health insurance or COBRA.

Employer or company name: Address: City:
State: Zip: - Phone:

Step 5. Tell us about the family members who get Medicaid.

First name:* MI: Last name:*    Suffix:
Medicaid ID: Social Security number:* Date of birth:* "MM/DD/YYYY"

Is this person pregnant?

Enter the numbers shown below in to the box provided before clicking Submit.

If you would like to receive your payment by direct deposit, please download our NC HIPP Direct Deposit form and return it to us within 10 days of your application submission.

Please call us at 1-855-MyNCHIPP (1-855-696-2447) or send email to if you experience problems with this form.

No time to fill out online? Download a North Carolina HIPP Application to fax or mail to us.