When you apply for the Bridge Plan, you’ll need to supply some information along with your completed application. Your Bridge Community Partner can supply you with a form.
Please mail your application to your local Community Partner. With your application, please include proof of residence, household income and assets by attaching (or bringing along) copies of the following documents, if applicable:
1. Proof of identity.
It can be a photo I.D. card, a, driver’s license, social security card, or a passport.
2. Proof of residence.
You’ll need something that shows you live in our coverage area — which includes Washington, D.C., parts of Northern Virginia, and parts of Maryland. You can bring a driver’s license, utility bill, lease agreement, or a letter from your landlord.
3. Verification of employment:
If you are employed, you’ll need W-2 forms, pay stubs, tax returns, or a letter from your employer verifying wages. You will also need three of your most current pay stubs showing earnings before taxes, deductions, and year-to-date earnings. You may bring checks or other proof of payment for all other sources of income.
4. Bank statement:
Please supply the last two bank statements you received for your savings and/or checking accounts.
5. Rejection notices:
Any applicable rejection notices from your state agency administering the Medicaid program.
Need more help with this? Contact your area Bridge Community Partner.
Bridge Plan Application
To apply for the Bridge Plan, please visit your local Community Partner to get an application. Complete and sign the application, and then mail it to your Community Partner along with the completed questionnaire form below. Do not leave any lines blank. If a question does not apply to you, write “N/A” in the space provided. If you don't complete the form or forget to sign it, the form will be returned to you.
Membership in the Bridge Plan is limited. Please submit your application as soon as possible. You will be notified by mail within 45 days of receipt of your application. The information you submit will remain confidential.
Need more help with this? Contact your area Bridge Community Partner.
Questionnaire:
Please complete this questionnaire and return it with your application. This is not required and does not impact your eligibility in the Kaiser Permanente Bridge Program.
