Children and Youth with Special Health Care Needs (CYSHCN)

Financial Eligibility

Financial eligibility is based on family income and size. The Financial Eligibility Guidelines show maximum earnings per family size.

Family income is determined by your IRS income tax form. This form is required with your application for services. Income consists of the Adjusted Gross Income (AGI) of the Federal IRS income tax form. An estimated income can be substituted for the AGI when no income tax form is available or when the income tax form is not available or when the income tax form is not reflective of the family’s current financial status.

Family size is determined by the number of person(s) listed on your income tax form, if available. Your local CYSHCN Service Coordinator can help you determine financial eligibility.

How to Apply

Contact the CYSHCN Service Coordinator to make a referral or download and complete the enrollment form by clicking on the link below.

Enrollment form, CC-1, can be printed by selecting the links below:

• English
• Spanish (Español)
• Somali
• Arabic
• French

Be sure to print both pages. The second page provides instructions on filling out the application. Contact your CYSHCN Service Coordinator for assistance in completing or submitting the enrollment form.