Use this form to request assistance from Peach State Health Plan.

Please share if you are having trouble in the following areas:

Food Housing Transportation Utilities (heat, electricity, water, etc.) Medical care, medicine, medical supplies Dental or vision services Applying for public benefits (WIC, SNAP, SSI, etc.) Understanding health information or completing medical forms More help with activities of daily living Childcare/other child-related activities Debt/loan repayment Legal issues Employment Access to a working telephone Access to the internet

Select the qualifying activities you need assistance with:

Employment, including self-employment On-the-Job Training Job Readiness Community Service Vocational Educational Training Enrollment in an Institution of Higher Education Enrollment and Active Engagement in the Georgia Vocational Rehabilitation Agency (GVRA) Vocational Rehabilitation Program