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San Francisco Health Plan

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



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
    • Acceptable documents include a CA Drivers Licensed/ID, US or Foreign Passport, Student ID, Permanent or Temporary Resident Card, Employment Authorization Card, Certificate of Naturalization, Certificate of US Citizenship, or Foreign ID


  • Proof of Residency
    • Acceptable documents include a CA Drivers Licensed/ID, Rental/Lease Agreement, Rental Payment Receipt, DMV Registration, Bank Statement/Letter, Utility Bill, SSI Award Letter, SF City ID Card, Affidavit of Support with 3rd Party Proof of S.F. Residency, Unemployment Benefits Statement, Cable Bill, Renter Insurance


  • Proof of Income
    • Acceptable documents include a Pay Stub, Tax Return, Alimony Received, Interest Income, Insurance Annuity Income, Rental Income, Taxable Government Benefits, Pensions/401K Income, 1040 w/ Schedule 1, or Bank Statement

Proof of Residency and Proof of Income must be within the past 45 days of the appointment date.

When uploading documents please click the blue upload button.

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.

Upload File(s)

Click Here to Upload

How did you hear about the Healthy San Francisco program and/or SF City Option Program? (Select all that apply)

What type of device will you have access to during our remote appointment?