Necessary Documents to Enroll
During your application appointment, you will be required to provide the following documentation:
- Personal identification
- Proof of residency
- Proof of household income and assets
This documentation helps the Application Assistor determine if you are eligible for Healthy San Francisco or for another public health insurance program. Your application will be considered incomplete until all required documents are submitted.
1. Personal Identification: ONLY ONE of the following documents is needed. Your personal identification must contain a photograph. For example:
| State Issued Driver License or ID | San Francisco ID Card |
| U.S. Passport | Student Picture ID |
| Certificate of Naturalization N-550/N-570 | U.S. Mariner Card |
| Permanent or Temporary Residency Card | Consular ID |
| School Record with date & place of birth/parents | Employment Authorization Card or ID |
| Certificate of Indian Blood/U.S. American Indian tribal document |
2. Proof of Residency: ONLY ONE of the following documents is needed. Your proof of residency must show your name.
| State Issued Driver License of ID | Current Pay Stub |
| Pension Check or Statement | Bank Statement |
| General Assistance Letter | DMV Registration |
| SFUSD School Registration | Utility Bill |
| Affidavit of Support | Social Security Award Letter |
| SSI Award Letter |
Affidavit of Support – This is a form that someone you live with can sign to vouch for your residency. They will need to provide one of the above items in their name. Click here to download.
3. Proof of Income: For EACH member of the household, please provide the most recent copy of one of the following documents as proof of income.
| Current Pay Stub | Current 1040 Tax Return |
| Signed Statement from Employer | Rental Income Receipts |
| Unemployment Benefits Statement | Veteran’s Statement |
| Worker Compensation Statement | Copy of Award Letter |
| Profit and Loss Statement for Self-Employment | Cash Income Statment |
Click here for a sample Signed Statement from Employer letter
Click here for a sample Profit and Loss Statement for Self-Employment letter
Click here for how to read paystub/bank statement guide
Click here for a sample Cash Income Statement
If you are self-employed or own a small business and do not have a current tax return, you may use a Profit and Loss Statement to document your income.
4. Proof of Asset: For EACH member of the household, please provide the most recent copy of one of the following documents as proof of assets.
| Bank statement ( must be an actual statement, not a transaction) | Itemized statements of retirement accounts, such as 401Ks and 403b (retirement stock value does not count toward family assets.) |
| Certification from the issuing institution of any stock, bond or certificate of deposit that is not for retirement. | Mutual Fund Statement with a market value |
| Bank letter |
5. Authorized Representative: If you would like to appoint someone to assist you with your application, communicate, and make decisions on your behalf in relation to your program participation, please complete the Authorized Representative Form with the person you would like to appoint.
Click here for a sample Authorized Representative Form
*Additional documentation may be required.