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San Francisco Health Plan

PO Box 194367, San Francisco, CA 94119-4367, US

415-547-7800

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Pre-Screening Form

Please complete the Pre-Screening Form to help us determine what benefit you may be eligible for.

For the best experience translating this form into another language, please access the form using a desktop computer. Please contact SFHP Customer Service at (415) 547-7800, if you have any questions.

Para obtener la mejor experiencia al traducir este formulario a otro idioma, acceda al formulario utilizando una computadora. Comuníquese con el Servicio al cliente de SFHP al (415) 547-7800, si tiene alguna pregunta.

如在填妥這表格時遇上翻譯問題，請使用桌上型電腦完成表格。如有任何疑問，請致電 (415) 547-7800 與SFHP客戶服務聯繫。

Para sa pinakamahusay na karanasan sa pagsasalin ng form na ito sa ibang wika, mangyaring i-access ang form gamit ang desktop computer. Mangyaring makipag-ugnay sa SFHP Customer Service sa (415) 547-7800, kung mayroon kang anumang mga katanungan.

Demographic Information

Full Name

Date of Birth

Required Documents

Please upload the following:

Proof of Identification - The document must have your name, date of birth, and photo. 
 
Acceptable documents include:
  • Driver’s license or state ID card
  • US or foreign passport
  • Permanent or temporary resident card
  • Employment authorization card (Work Permit)
  • Certificate of Naturalization
  • Foreign ID (consular or voter ID)
  • SF City ID
 
Proof of Residency - The document must have your name, current address, and must be dated within 45 days of the appointment date. 
 
Acceptable documents include:
  • Unexpired CA Drivers License/ID or SF City ID
  • Rental/Lease Agreement or Payment Receipt
  • DMV Registration
  • Bank Statement
  • Utility Bill
  • SSA or Unemployment Benefits Award Letter
  • Cable, Internet, Landline Bill
  • Residential Program Letter
  • Paystub
  • Affidavit of Support w/ 3rd Party Proof of SF Residency​
 
Proof of Household Income - Documents must have your name and be dated within 45 days of the appointment date.
 
Acceptable documents include:
  • 2-3 Consecutive Paystubs
  • 1040 Tax Return with Associated Schedules
  • Profit and Loss Statement for the last 3 months
  • Taxable Government Benefits
  • Pensions/401K Income
  • SSA or Unemployment Benefits Award Letter
  • Affidavit of Support
  • Rental Income

If you have any questions or are unsure whether a document is acceptable, please view the Acceptable Verification Document List or call our Customer Service at 415-547-7800 for assistance.

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