Washington Health Care Authority · Washington
Family Planning Only
Free family planning services, including birth control, for people who meet the income and coverage rules. Insured people may qualify for confidential services.
Taking applicationsChecked October 11, 2026
Coverage for family planning visits, birth control and related tests. Coverage lasts 12 months after approval even if income changes.
Apply for me
We use your saved answers and ask only what is missing. You review and sign before anything is sent.
Who can apply
- FPO serves Washington residents who meet its income, pregnancy and coverage rules.
The questions on the application (109)
Are you currently pregnant? · if it applies
Yes · No
First Name (use your full legal name) · if it applies
Middle Initial · optional · if it applies
Last Name · if it applies
Male Female · optional · if it applies
Male · Female
Date of birth · if it applies
Social Security Number (if you have one) · optional · if it applies
Resident of Washington? · if it applies
Yes · No
Address where you live · optional · if it applies
Apt. # · optional · if it applies
City · optional · if it applies
State · optional · if it applies
Zip Code · optional · if it applies
Mailing address · optional · if it applies
Apartment unit · optional · if it applies
City · optional · if it applies
State · optional · if it applies
Zip Code · optional · if it applies
Main phone number · optional · if it applies
Additional phone number · optional · if it applies
Can we contact you at the phone numbers provided? · optional · if it applies
Yes · No
Email address · optional · if it applies
Do you have trouble speaking, reading, or writing English? · optional · if it applies
Yes · No
Do you need an interpreter? · optional · if it applies
Yes · No
What language do you speak? · optional · if it applies
Do you have Private health insurance or Apple Health (Medicaid) coverage? · if it applies
Yes · No
I am seeking confidential family planning services and I am 26 years old or younger · optional · if it applies
I am a victim of domestic violence and I am covered under my abuser’s health insurance. · optional · if it applies
Within the last 30 days, have you been denied Apple Health (Medicaid) full-scope coverage through wahealthplanfinder.org? · if it applies
Yes · No
I choose to apply for family planning only coverage and am making an informed choice to not apply for full-scope Apple Health (Medicaid). · optional · if it applies
Citizen or Non-citizen status: (check one): · optional · if it applies
U.S. citizen or U.S. National · Non-citizen lawfully present in the U.S. · Other
Immigration document type · optional · if it applies
“A” number · optional · if it applies
Receipt number or other number · optional · if it applies
Foreign passport number · optional · if it applies
Country of residence · optional · if it applies
Date of entry · optional · if it applies
Document expiry date · optional · if it applies
What will your tax filing status be for this year? · optional · if it applies
Single filer · Married filing separately · Married filing jointly · Tax dependent of someone from household · Tax dependent of someone outside household · Non-tax filer
Are you legally married? · optional · if it applies
Yes · No
If yes, your spouse’s full legal name: · optional · if it applies
If you file a tax return, how many tax dependents do you claim? · optional · if it applies
If not, how many children do you have? · optional · if it applies
Have you quit or lost a job in the last 90 days? · optional · if it applies
Yes · No
If yes, the business’s name: · optional · if it applies
Employment end date · optional · if it applies
Has your spouse quit or lost a job in the last 90 days? · optional · if it applies
Yes · No
If yes, the business’s name: · optional · if it applies
Employment end date · optional · if it applies
Race/Ethnic Background · optional · if it applies
7 choices
Other: · optional · if it applies
Tribe name: · optional · if it applies
Name/Organization · optional · if it applies
Telephone number · optional · if it applies
Mailing address · optional · if it applies
Aptartment unit · optional · if it applies
City · optional · if it applies
State · optional · if it applies
Zip Code · optional · if it applies
Are you currently pregnant? · if it applies
Yes · No
First Name (use your full legal name) · if it applies
Middle Initial · optional · if it applies
Last Name · if it applies
Male Female · optional · if it applies
Male · Female
Date of birth · if it applies
Social Security Number (if you have one) · optional · if it applies
Resident of Washington? · if it applies
Yes · No
Address where you live · optional · if it applies
Apt. # · optional · if it applies
City · optional · if it applies
State · optional · if it applies
Zip Code · optional · if it applies
Mailing address · optional · if it applies
Apt. # · optional · if it applies
City · optional · if it applies
State · optional · if it applies
Zip Code · optional · if it applies
Home/cell/preferred number · optional · if it applies
Work/message number · optional · if it applies
Can we contact you at the phone numbers provided? · optional · if it applies
Yes · No
E-mail address · optional · if it applies
Do you have trouble speaking, reading, or writing English? · optional · if it applies
Yes · No
Do you need an interpreter? · optional · if it applies
Yes · No
What language do you speak? · optional · if it applies
Do you have Private health insurance or Apple Health (Medicaid) coverage? · if it applies
Yes · No
18 years or younger; or · optional · if it applies
Victim of domestic violence and I am covered under my abuser’s health insurance · optional · if it applies
I choose to apply for family planning only coverage and am making an informed choice to not apply for full-scope Apple Health (Medicaid). · optional · if it applies
What will your tax filing status be for this year? · optional · if it applies
Single Filer · Married Filing Separately · Married Filing Jointly · Tax Dependent of Someone from Household · Tax Dependent of Someone Outside Household · Non-Tax Filer
Are you legally married? · optional · if it applies
Yes · No
If yes, your spouse’s full legal name · optional · if it applies
If you file a tax return, how many tax dependents do you claim? · optional · if it applies
If not, how many children do you have? · optional · if it applies
Have you quit or lost a job in the last 90 days? · optional · if it applies
Yes · No
If yes, the business’s name: · optional · if it applies
Employment end date: · optional · if it applies
Has your spouse quit or lost a job in the last 90 days? · optional · if it applies
Yes · No
If yes, the business’s name: · optional · if it applies
Employment end date: · optional · if it applies
Race/Ethnic Background · optional · if it applies
7 choices
Other: · optional · if it applies
Tribe name: · optional · if it applies
Name / Organization · optional · if it applies
Telephone number · optional · if it applies
Mailing address · optional · if it applies
Apt. # · optional · if it applies
City · optional · if it applies
State · optional · if it applies
Zip Code · optional · if it applies
Earned by you: answered for each person (Name of current employer (1st Job), Telephone Number, Self-Employed?, Gross monthly income before taxes, (and/or net monthly income for self-employment)).
Earned by you: answered for each person (Name of current employer (2nd Job), Telephone Number, Self-Employed?, Gross monthly income before taxes, (and/or net monthly income for self-employment)).
Earned by other household members: answered for each person (Name of current employer (1st Job), Telephone Number, Self-Employed?, Gross monthly income before taxes, (and/or net monthly income for self-employment)).
Earned by other household members: answered for each person (Name of current employer (2nd Job), Telephone Number, Self-Employed?, Gross monthly income before taxes, (and/or net monthly income for self-employment)).
Alimony/spousal support paid: answered for each person (Monthly amount:, Who receives this:).
Rental, and/or royalty income (net): answered for each person (Monthly amount:, Who receives this:).
Social Security/Railroad Retirement benefits: answered for each person (Monthly amount:, Who receives this:).
Unemployment: answered for each person (Monthly amount:, Who receives this:).
Retirement income, including pension, annuity, and/or IRA distribution: answered for each person (Monthly amount:, Who receives this:).
Dividend, stocks, shares, capital gains, foreign, trust/ other investment income: answered for each person (Monthly amount:, Who receives this:).
Taxable tribal income: answered for each person (Monthly amount:, Who receives this:).
Farming and fishing income (net) Other taxable income: answered for each person (Monthly amount:, Who receives this:).
Other taxable income: answered for each person (Monthly amount:, Who receives this:).
Alimony/spousal support paid: answered for each person (Monthly amount:, Who pays this:).
Contribution/IRA or pre-tax retirement account contributions: answered for each person (Monthly amount:, Who pays this:).
Student loan interest payments: answered for each person (Monthly amount:, Who pays this:).
Moving costs for members of the armed forces: answered for each person (Monthly amount:, Who pays this:).
Educator expenses: answered for each person (Monthly amount:, Who pays this:).
Health savings account contributions: answered for each person (Monthly amount:, Who pays this:).
Penalty on early withdrawal of savings: answered for each person (Monthly amount:, Who pays this:).
Certain claimable business expenses: answered for each person (Monthly amount:, Who pays this:).
Earned by you: answered for each person (Name of current employer (1st Job), Telephone Number, Self-Employed?, Gross monthly income before taxes, (and/or net monthly income for self-employment)).
Earned by you: answered for each person (Name of current employer (2nd Job), Telephone Number, Self-Employed?, Gross monthly income before taxes, (and/or net monthly income for self-employment)).
Earned by other household members: answered for each person (Name of current employer (1st Job), Telephone Number, Self-Employed?, Gross monthly income before taxes, (and/or net monthly income for self-employment)).
Earned by other household members: answered for each person (Name of current employer (2nd Job), Telephone Number, Self-Employed?, Gross monthly income before taxes, (and/or net monthly income for self-employment)).
Alimony/spousal support: answered for each person (Monthly amount:, Who receives this:).
Rental, and/or royalty income (net): answered for each person (Monthly amount:, Who receives this:).
Social Security/Railroad Retirement benefits: answered for each person (Monthly amount:, Who receives this:).
Unemployment: answered for each person (Monthly amount:, Who receives this:).
Retirement income, including: pension, annuity, and/or IRA distribution: answered for each person (Monthly amount:, Who receives this:).
Dividend, stocks, shares, capital gains, foreign, trust/ other investment income: answered for each person (Monthly amount:, Who receives this:).
Taxable tribal income: answered for each person (Monthly amount:, Who receives this:).
Farming and fishing income (net): answered for each person (Monthly amount:, Who receives this:).
Other taxable income: answered for each person (Monthly amount:, Who receives this:).
Alimony/spousal support PAID: answered for each person (Monthly amount:, Who pays this:).
Contribution/IRA or pre-tax retirement account contributions: answered for each person (Monthly amount:, Who pays this:).
Student loan interest payments: answered for each person (Monthly amount:, Who pays this:).
Moving costs for members of the armed forces: answered for each person (Monthly amount:, Who pays this:).
Educator expenses: answered for each person (Monthly amount:, Who pays this:).
Health savings account contributions: answered for each person (Monthly amount:, Who pays this:).
Penalty on early withdrawal of savings: answered for each person (Monthly amount:, Who pays this:).
Certain claimable business expenses: answered for each person (Monthly amount:, Who pays this:).
What you agree to
BY FILLING OUT THIS APPLICATION, YOU ACKNOWLEDGE YOU ARE APPLYING FOR FAMILY PLANNING
SERVICES ONLY.
I understand that:
• HCA may ask me to prove the information I provide. HCA may help me get the proof or contact other agencies or
persons for it.
• My information may be reviewed by other state or federal agencies. This information will NOT be shared with
U.S. Customs and Immigration Services (USCIS).
• By asking for and receiving medical coverage assistance, I assign to the state of Washington all rights to any
medical support and to any third party payments for medical care.
• I understand this application is for family planning services to prevent pregnancy only. If I need other medical
coverage assistance, I can apply at Washington Healthplanfinder (wahealthplanfinder.org). If I need financial
assistance or food stamps, I can apply at a DSHS Community Services Office or Washington Connection
(washingtonconnection.org).
• I must respond to any requests for additional information within 15 business days or my application will be
denied and I may be responsible for all charges incurred through my family planning provider’s office.
I have read and understood the information in this application. I declare, under penalty of perjury, the
information I have given in this application is true, correct, and complete to the best of my knowledge.
By filling out this application, you acknowledge you are applying for family planning services only.
I understand that:
• HCA may ask me to prove the information I provide. HCA may help me get the proof or contact other agencies or
persons for it.
• My information may be reviewed by other state or federal agencies.
• By asking for and receiving medical coverage assistance, I assign to the state of Washington all rights to any medical
support and to any third party payments for medical care.
• I understand this application is for family planning services to prevent pregnancy only. If I need other medical
coverage assistance, I can apply at Washington Healthplanfinder (wahealthplanfinder.org). If I need financial
assistance or food stamps, I can apply at a DSHS Community Services Office or Washington Connection
(washingtonconnection.org).
• I must respond to any requests for additional information within 15 business days or my application will be denied
and I may be responsible for all charges incurred through my family planning provider’s office.
I have read and understood the information in this application. I declare, under penalty of perjury, the information I have
given in this application is true, correct, and complete to the best of my knowledge.
After you apply
- HCA may contact you by phone or mail for more information.
- Reapply after HCA mails a notice that your 12 months of coverage will end.
- You can apply for full-scope Apple Health at any time.
- You can appeal an eligibility decision within 90 days.
- HCA processes applications within 45 days.
- Respond to requests for more information within 15 business days or HCA may deny the application.
- If approved, coverage starts on the first day of the month you applied.
- HCA mails an approval or denial letter.
- Confidential services let you choose contact information, prevent mailed Explanation of Benefits notices and route calls to a live person.
Before you send it
- Leave the SSN and immigration document number blank if you do not have them.
- If you were denied full-scope Apple Health within 30 days and your household has not changed, skip to section 10 on form 13-781.
- For self-employment, report net monthly income instead of wages before taxes.
- List more than two employers on a separate sheet.
- The resident signs and dates the selected form after reading its own declaration. Signature and date fields are not ordinary walkthrough questions.
- The still-public HCA 13-0058 (3/21) says confidential services are for people 18 or younger. HCA 13-781 (06/26) and the 2026 coverage brochure say 26 or younger. The screener follows the current 2026 rule; do not deny an insured person aged 19 through 26 based on the old checkbox.
- Only the attestations on the selected application apply.
What we could not check
- You can apply at any time. No seasonal opening or closing date is stated.
- Some details here could not be confirmed. Check with Washington Health Care Authority before you apply.