SF MRA Enrollment Form
Complete this form to determine if you qualify for a Medical Reimbursement Account (SF MRA). After you submit this form, SF City Option (SFCO) will let you know if you are eligible for SF MRA within 1-3 weeks.
If you have any questions, please email firstname.lastname@example.org.
* Required Fields
Date of Birth
Social Security Number *
SF City Option will not share your personal information with immigration or law enforcement. Your immigration status will not affect your eligibility for the SF City Option program.
We will disclose your personally identifiable information, including your SSN, date of birth, and name, to Covered California to determine whether you are eligible to apply your SF City Option funds to the payment of premiums for an insurance plan purchased through Covered California and, if you are eligible, to assist you with applying your SF City Option funds in this manner. If you do not authorize SF City Option to disclose your personally identifiable information to Covered California, please check the box below.
By providing your phone number and/or email address you agree to receive emails, calls, or texts from the SFCO program. If you want to stop receiving SFCO emails, calls and/or texts, please email email@example.com.
Preferred Method of Contact
What is your race?
Are you of Latino/a/x, or of Spanish origin?