Contact HICAP Form

We can help you with Medicare. HICAP, the Health Insurance Counseling and Advocacy Program, provides free, unbiased education, counseling, and advocacy about Medicare and related health insurance.
Please use this form to submit a question or a request for assistance with Medicare. We will respond generally within 2 to 3 business days.
Complete the form below. An *asterisk indicates a required field. Do not put any personal information on this form, such as Medicare number or insurance member number.
Client's Name*
First Name Last Name
Client's Zip Code*
Please enter your HOME Zip Code
Client's Year of Birth (example: 1947)*
If you are contacting us on behalf of someone else, enter your name here.
Your Email Address*
Enter Email Confirm Email
Your Phone*
Enter the best phone number to be reached on week days.
How do you prefer HICAP to contact you?
(check all that apply)
- PHONE
- EMAIL
If we need to contact you by phone, what are the best times to reach you.
(examples: "weekday mornings", or "after 3 pm")
Would you use ZOOM Video Conferencing to talk with a Counselor?
- YES
Please tell us how HICAP can help you with your Medicare.*
Please give us a brief summary of your questions or issues. A counselor will contact you for additional details. Do not include any personal information such as Medicare number.
PLEASE NOTE: It may take 2 or 3 days for you to hear from us. Please do not submit a second form, or call our phone number. Multiple requests from the same person will slow down the response. Thank you for your cooperation.
Name
This field is for validation purposes and should be left unchanged.

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This project was supported, in part by grant number 90SAPG0094-01-00*, from the U.S. Administration for Community Living (ACL), Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official ACL policy

Some material on this website has been obtained from public records. Maps are Copyright © 2020 by Google Inc. or Microsoft Inc. The balance of the material is Copyright © 2008-2020 by Contra Costa County HICAP. All Rights are Reserved and material cannot be used without written permission.

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Contact HICAP Form

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