You may fill out the application form in private. Please contact the county assistance office if you would like help.Use this application to see what coverage you qualify for. Fill out this form. 2. Sign and date it on page 1 and page 15. 3. Gov to apply online. The primary duty of the proposer is to fill out the proposal form and also to make sure that the proposal contains all the details correctly. PA Health and Wellness provides quality Medicaid and health insurance plans in Pennsylvania.