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Individual Short Form

Individual Short Form

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Published by Jenifer Sanchez
Application for Health Coverage & Help Paying Costs (Short Form)
Application for Health Coverage & Help Paying Costs (Short Form)

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Published by: Jenifer Sanchez on Apr 30, 2013
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03/31/2014

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Application for Health Coverage & Help Paying Costs (Short Form)
�
   t   h   i   n   g   s   t   o   k   n   o   w 
Use this applicationto see whatcoverage youqualify for
Affordable private health insurance plans that offer comprehensivecoverage to help you stay ellA ne tax credit that can immediately help pay your premiums forhealth coverageFree or lo-cost insurance from Medicaid or the Children’s ealthnsurance Program (CP)
Who can use thisapplication?
ingle adults ho:

Aren’t offered health coverage from their employerDon’t have any dependents and can’t be claimed as a dependent onsomeone else’s tax return
NOTE:
f any of the folloing apply, you need to ll out a different formto mae sure you get the most benets possible:

You’re married or have dependent children.You ere in the foster care system, and you’re under age 26.You have items that can be deducted from your income. f your onlydeduction is student loan interest, you
can
use this form.You’re American ndian or Alasa ative.
Apply fasteronline
Apply faster online at
.
What you mayneed to apply
Your ocial ecurity number (or document number if you’re a legalimmigrant)Employer and income information (for example, from paystubs,w-2 forms, or age and tax statements)
Why do we ask forthis information?
we as about income and other information to let you no hatcoverage you qualify for and if you can get any help paying for it.
We’ll keep all the information you provide private, as required by law.
What happensnext?
end your complete, signed application to the address on page 3.
Ifyou don’t have all the information we ask for, sign and submit yourapplication anyway.
we’ll follo up ith you ithin 1–2 ees. Fillingout this application doesn’t mean you have to buy health coverage.
Get help with thisapplication
.
Phone:
Call our elp Center at
1-800-XXX-XXXX.In person:
here may be counselors in your area ho can help.Visit
, or call
1-800-XXX-XXXX
for more information.
En Español:
Llame a nuestro centro de ayuda gratis al
1-800-XXX-XXXX.
NEED HELP WITH YOUR APPLICATION?
 
Visit
HealthCare.gov
or call us at
1-800-XXX-XXXX
. Para obtener una copia de esteformulario en Español, llame
1-800-XXX-XXXX
. If you need help in a language other than English, call
1-800-XXX-XXXX
and tell thecustomer service representative the language you need. We’ll get you help at no cost to you. TTY users should call
1-800-XXX-XXXX
.
 
 
Page 1 of 3
NEED HELP WITH YOUR APPLICATION?
 
Visit
HealthCare.gov
or call us at
1-800-XXX-XXXX
. Para obtener una copia de esteformulario en Español, llame
1-800-XXX-XXXX
. If you need help in a language other than English, call
1-800-XXX-XXXX
and tell thecustomer service representative the language you need. We’ll get you help at no cost to you. TTY users should call
1-800-XXX-XXXX
.
STEP 1
Tell us about yourself.
1. First name, Middle name, Last name, & uffix2. ome address (Leave blan if you don’t have one.) 3. Apartment or suite number4. City 5. tate 6. Zip code 7. County8. Mailing address (if different from home address) 9. Apartment or suite number10. City 11. tate 12. ZP code 13. County14. Phone number
( )
15. ther phone number
( )
16. Do you ant to get information about this application by email? Yes oEmail address:17. Preferred spoen or ritten language (if not English)18. Date of birth (mm/dd/yyyy) 19. exMale Female20. ocial ecurity number ()
--
We need this if you want health coverage and have an SSN.
we use s to chec income and other information to see if you’reeligible for help ith health coverage costs. f you need help getting an , call 1-800-772-1213 or visit
socialsecurity.gov
. Y usersshould call 1-800-325-0778.21. Are you a U.. citizen or U.. national? Yes o22.
If you aren’t a U.S. citizen or U.S. national,
do you have eligible immigration status?Yes. Fill in your document type and D number belo.a. mmigration document typeb. Document D numberc. ave you lived in the U.. since 1996? Yes od. Are you a veteran or an active-duty member of the U.. military? Yes o23. Are you pregnant? Yes o
If yes,
ho many babies are expected during this pregnancy?24. Do you have a physical, mental, or emotional health condition that causes limitations in activities (lie bathing, dressing, dailychores, etc.) or live in a medical facility or nursing home? Yes o25.
If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.)
Mexican Mexican American Chicano/a Puerto Rican Cuban ther26.
Race (OPTIONAL—check all that apply.)
whiteBlac or AfricanAmericanAmerican ndian orAlasa ativeAsian ndianChineseFilipinoJapanesekoreanVietnamesether Asianative aaiianuamanian or Chamorroamoanther Pacic slanderther
 
 
Page 2 of 3
STEP 2
Current job & income information
Employed –
f you’re currently employed, tell us about your income. tart ith question 1.
Not Employed –
ip to question 11.
Self Employed –
ip to question 10.
CURRENT JOB 1:
1. Employer name and address2. Employer phone number
( )
3. Average hours ored each ee4. wages/tips (before taxes)ourly weely Every 2 ees ice a month Monthly Yearly
$CURRENT JOB 2:
(f you have more jobs and need more space, attach another sheet of paper.)5. Employer name and address6. Employer phone number
( )
7. Average hours ored each ee8. wages/tips (before taxes)ourly weely Every 2 ees ice a month Monthly Yearly
$
9.
In the past year, did you:
Change jobs top oring tart oring feer hours one of these10.
If self-employed, answer the following questions:
a. ype of orb. o much net income (profits once business expenses arepaid) ill you get from this self-employment this month?
$
11.
OTHER INCOE THIS ONTH:
Chec all that apply, and give the amount and ho often you get it.
NOTE:
You don’t need to tell us about child support, veteran’s payment, or upplemental ecurity ncome ().oneUnemployment
$
o often?Pensions
$
o often?ocial ecurity
$
o often?Retirement accounts
$
o often?Alimony received
$
o often?et farming/fishing
$
o often?ther income
$
o often?ype:12. Do you pay student loan interest (not the amount of the loan) that can be deducted on a federal income tax return?
YES.If yes,
ho much
$
o often?
NO.
13. Complete only if your income changes from month to month. f you don’t expect changes to your monthlyincome, sip to step 3.
YEARLY INCOE:
Your total income
this year
$
Your total income
next year
(if you thin it ill be different)
$
STEP 3
Your health coverage
1.
Are you enrolled in health coverage now from any of the following?YES.If yes,
chec hich coverage you have.
NO.
MedicaidCPMedicareRCARE (don’t chec if you have DirectCare or Line of Duty)Peace CorpsVA health care programstherame of health insurancePolicy number
NEED HELP WITH YOUR APPLICATION?
 
Visit
HealthCare.gov
or call us at
1-800-XXX-XXXX
. Para obtener una copia de esteformulario en Español, llame
1-800-XXX-XXXX
. If you need help in a language other than English, call
1-800-XXX-XXXX
and tell thecustomer service representative the language you need. We’ll get you help at no cost to you. TTY users should call
1-800-XXX-XXXX
.

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