Apply Online

Need healthcare? Please fill out the following short form to see if you qualify for HNG.  A member of our staff will contact you.  If you have questions, please call 704-874-1901.

Note:  Chronic medical conditions include diabetes, high blood pressure, asthma, heart disease, COPD, etc.

Enrollment Form

* 1. Are you a Gaston County resident?

Yes

No

* 2. Are you age 18 or older?

Yes

No

* 3. Is your household income 100% of federal poverty or less based on the table shown above?

Yes

No

* 4. Do you have any kind of health insurance (private insurance, Medicaid, Medicare, VA benefits)?

Yes

No

* 5. Do you have a chronic medical condition?

Yes

No

* Your Name

* Your Email Address

Your Phone Number

Wordpress plugin expert and Rockville Web Developer Taylor Lovett

* Indicates required field.