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Request for Assistance Form
Request for Assistance Form
Please submit this form to request free, confidential assistance applying for health insurance and SNAP or accessing other resources. A member of the Excel Academy Benefits Access Team will contact you.
Parent Name(s):
Email:
Today's Date:
Excel Student Name(s):
Excel Academy Campus:
Excel Academy East Boston
Excel Academy Chelsea
Excel Academy Orient Heights
Excel Academy Charter High School
Grade:
5
6
7
8
9
10
11
Phone:
Best time(s) to contact you:
What is your Excel student's health insurance?
MassHealth Standard
MassHealth Limited
MassHealth Family Assistance
Health Safety Net
Harvard Pilgrim
Children's Medical Security Plan
Blue Cross Blue Shield
No insurance
Other
Where does your Excel student receive primary care?
Pediatric Medical Care
MGH Chelsea
East Boston Neighborhood Health Center
Boston Medical Center
Harvard Vanguard
North End Waterfront Health
Children's Hospital
Other
How can we assist you?
Assistance applying for health insurance
Assistance renewing health insurance
Assistance applying for SNAP (food stamps)
Questions related to immigration, citizenship status, or legal resources
Other assistance
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