1. health and fitness

FormApproved
OMBNo.0938-1191
THINGS TO KNOW
Application for Health Coverage & Help Paying Costs (Short Form)
Use this application
to see what
coverage you
qualify for
• Affordableprivatehealthinsuranceplansthatoffercomprehensive
coveragetohelpyoustaywell
• Anewtaxcreditthatcanimmediatelyhelppayyourpremiumsforhealth
coverage
• Freeorlow-costinsurancefromMedicaidortheChildren’sHealth
InsuranceProgram(CHIP)
Who can use this
application?
Singleadultswho:
• Aren’tofferedhealthcoveragefromtheiremployer
• Don’thaveanydependentsandcan’tbeclaimedasadependenton
someoneelse’staxreturn
NOTE:Ifanyofthefollowingapply,youneedtofilloutadifferentformto
makesureyougetthemostbenefitspossible:
• You’remarriedorhavedependentchildren.
• Youwereinthefostercaresystem,andyou’reunderage26.
• Youhaveitemsthatcanbedeductedfromyourincome.Ifyouronly
deductionisstudentloaninterest,youcanusethisform.
• You’reAmericanIndianorAlaskaNative.
Apply faster
online
ApplyfasteronlineatHealthCare.gov.
What you may
need to apply
• YourSocialSecuritynumber(ordocumentnumberifyou’realegal
immigrant)
• Employerandincomeinformation(forexample,frompaystubs,
W-2forms,orwageandtaxstatements)
Why do we ask for
this information?
Weaskaboutincomeandotherinformationtoletyouknowwhatcoverage
youqualifyforandifyoucangetanyhelppayingforit.
We’ll keep all the information you provide private and secure, as
required by law. ToviewthePrivacyActStatement,goto
HealthCare.gov/placeholder.
What happens
next?
Sendyourcomplete,signedapplicationtotheaddressonpage3.If you
don’t have all the information we ask for, sign and submit your
application anyway.We’llfollowupwithyouwithin1–2weeks.Fillingout
thisapplicationdoesn’tmeanyouhavetobuyhealthcoverage.
Get help with this
application
• Online: HealthCare.gov.
• Phone: CallourHelpCenterat1-800-XXX-XXXX.
• In person: Theremaybecounselorsinyourareawhocanhelp.
VisitHealthCare.gov,orcall1-800-XXX-XXXXformoreinformation.
• En Español:Llameanuestrocentrodeayudagratisal
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 este formulario
en Español, llame 1-800-XXX-XXXX. If you need help in a language other than English, call 1-800-XXX-XXXX and tell the customer 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.Firstname,Middlename,Lastname,&Suffix
2.Homeaddress(Leaveblankifyoudon’thaveone.)
3.Apartmentorsuitenumber
4.City
5.State
6.Zipcode
8.Mailingaddress(ifdifferentfromhomeaddress)
7.County
9.Apartmentorsuitenumber
10.City
11.State
12.ZIPcode
14.Phonenumber
15.Otherphonenumber
16. Doyouwanttogetinformationaboutthisapplicationbyemail?
Yes
()–
13.County
()–
No
Emailaddress:
17.Whatisyourpreferredspokenorwrittenlanguage(ifnotEnglish)?
18.Dateofbirth(mm/dd/yyyy)
19.Sex
Male
-
20.SocialSecuritynumber(SSN)
Female
-
We need this if you want health coverage and have an SSN. WeuseSSNstocheckincomeandotherinformationtoseeifyou’reeligible
forhelpwithhealthcoveragecosts.IfyouneedhelpgettinganSSN,call1-800-772-1213orvisitsocialsecurity.gov.TTYusersshouldcall
1-800-325-0778.
21. AreyouaU.S.citizenorU.S.national?
Yes
No
22. If you aren’t a U.S. citizen or U.S. national,doyouhaveeligibleimmigrationstatus?
Yes.FillinyourdocumenttypeandIDnumberbelow.
a.Immigrationdocumenttype
b.DocumentIDnumber
c.HaveyoulivedintheU.S.since1996?
Yes
No
d.Areyouaveteranoranactive-dutymemberoftheU.S.military?
23. Areyoupregnant?
Yes
Yes
No
No
If yes,howmanybabiesareexpectedduringthispregnancy?
24. Doyouhaveaphysical,mental,oremotionalhealthconditionthatcauseslimitationsinactivities(likebathing,dressing,dailychores,etc.)
orliveinamedicalfacilityornursinghome? Yes No
25. If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.)
Mexican MexicanAmerican Chicano/a PuertoRican
Cuban
Other
26. Race (OPTIONAL—check all that apply.)
White
BlackorAfrican
American
AmericanIndianor
AlaskaNative
AsianIndian
Chinese
Filipino
Japanese
Korean
Vietnamese
OtherAsian
NativeHawaiian
GuamanianorChamorro
Samoan
OtherPacificIslander
Other
NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-800-XXX-XXXX. Para obtener una copia de este formulario
en Español, llame 1-800-XXX-XXXX. If you need help in a language other than English, call 1-800-XXX-XXXX and tell the customer 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
STEP 2
Current job & income information
Employed – Ifyou’recurrentlyemployed,tellusaboutyourincome.Startwithquestion1.
Not Employed – Skiptoquestion11.
Self Employed – Skiptoquestion10.
CURRENT JOB 1:
1.Employernameandaddress
4.Wages/tips(beforetaxes)
2.Employerphonenumber
()–
Hourly
Weekly
Every2weeks
Twiceamonth
3.Averagehoursworkedeachweek
Monthly
Yearly
$
CURRENT JOB 2: (Ifyouhavemorejobsandneedmorespace,attachanothersheetofpaper.)
5.Employernameandaddress
8.Wages/tips(beforetaxes)
6.Employerphonenumber
()–
Hourly
Weekly
Every2weeks
Twiceamonth
7.Averagehoursworkedeachweek
Monthly
Yearly
$
9.In the past year, did you:
Changejobs
Stopworking
Startworkingfewerhours
Noneofthese
10.If self-employed, answer the following questions:
a.Typeofwork
b. Howmuchnetincome(profitsoncebusinessexpensesarepaid)
willyougetfromthisself-employmentthismonth?
$
11.OTHER
INCOME THIS MONTH: Checkallthatapply,andgivetheamountandhowoftenyougetit.
NOTE: Youdon’tneedtotellusaboutchildsupport,veteran’spayment,orSupplementalSecurityIncome(SSI).
None
Retirementaccounts
$
Howoften?
Unemployment
$
Howoften?
Alimonyreceived
$
Howoften?
Pensions
$
Howoften?
Net farming/fishing
$
Howoften?
SocialSecurity
$
Howoften?
Otherincome
$
Howoften?
Type:
12.Doyoupaystudentloaninterest(nottheamountoftheloan)thatcanbedeductedonafederalincometaxreturn?
YES. If yes, howmuch$
NO.
Howoften?
13.YEARLY INCOME: Completeonlyifyourincomechangesfrommonthtomonth.Ifyoudon’texpectchangestoyourmonthlyincome,
skiptostep3.
Yourtotalincomethis year
Yourtotalincomenext year(ifyouthinkitwillbedifferent)
$
$
STEP 3
Your health coverage
1. Are you enrolled in health coverage now from any of the following?
YES. If yes, checkwhichcoverageyouhave.
NO.
Medicaid
VAhealthcareprograms
CHIP
Other
Medicare
Nameofhealthinsurance
TRICARE(don’tcheckifyouhaveDirect
CareorLineofDuty)
PeaceCorps
Policynumber
NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-800-XXX-XXXX. Para obtener una copia de este formulario
en Español, llame 1-800-XXX-XXXX. If you need help in a language other than English, call 1-800-XXX-XXXX and tell the customer 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 2 of 3
STEP 4
Read & sign this application.
• I’msigningthisapplicationunderpenaltyofperjury,whichmeansI’veprovidedtrueanswerstoallthequestionsonthisform
tothebestofmyknowledge.IknowthatImaybesubjecttopenaltiesunderfederallawifIintentionallyprovidefalseor
untrueinformation.
• IknowthatImusttelltheHealthInsuranceMarketplaceifanythingchanges(andisdifferentthan)whatIwroteonthis
application.IcanvisitHealthCare.gov orcall1-800-XXX-XXXXtoreportanychanges.Iunderstandthatachangeinmy
informationcouldaffectmyeligibility.
• Iknowthatunderfederallaw,discriminationisn’tpermittedonthebasisofrace,color,nationalorigin,sex,age,sexual
orientation,genderidentity,ordisability.Icanfileacomplaintofdiscriminationbyvisitingwww.hhs.gov/ocr/office/file.
• IconfirmthatI’mnotincarcerated(detainedorjailed).
• IconfirmthatnextyearIexpecttofileafederalincometaxreturn,won’tclaimdependentsonthatreturn,andcan’tbe
claimedasadependentonanyoneelse’sfederalincometaxreturn.
• IconfirmthatI’mnotofferedhealthcoveragefromanemployer.
Weneedthisinformationtocheckyoureligibilityforhelppayingforhealthcoverageifyouchoosetoapply.We’llcheckyour
answersusinginformationinourelectronicdatabasesanddatabasesfromtheInternalRevenueService(IRS),SocialSecurity,the
DepartmentofHomelandSecurity,and/oraconsumerreportingagency.Iftheinformationdoesn’tmatch,wemayaskyouto
sendusproof.
Renewal of coverage in future years
Tomakeiteasiertodeterminemyeligibilityforhelppayingforhealthcoverageinfutureyears,IagreetoallowtheMarketplace
touseincomedata,includinginformationfromtaxreturns.TheMarketplacewillsendmeanotice,letmemakeanychanges,
andIcanoptoutatanytime.
Yes,renewmyeligibilityautomaticallyforthenext
5years(themaximumnumberofyearsallowed),orforashorternumberofyears:
4years
3years
2years
1year
Don’tuseinformationfromtaxreturnstorenewmycoverage.
If I’m eligible for Medicaid
IfIenrollinMedicaid,I’mgivingtheMedicaidagencymyrightstopursueandgetanymoneyfromotherhealthinsurance,legal
settlements,orotherthirdparties.
My right to appeal
IfIthinktheMarketplaceorMedicaid/Children’sHealthInsuranceProgram(CHIP)hasmadeamistake,Icanappealitsdecision.
ToappealmeanstotellsomeoneattheMarketplaceorMedicaid/CHIPthatIthinktheactioniswrong,andaskforafairreview
oftheaction.IknowthatIcanfindouthowtoappealbycontactingtheMarketplaceat1-800-XXX-XXXX.IknowthatIcanbe
representedintheprocessbysomeoneotherthanmyself.Myeligibilityandotherimportantinformationwillbeexplainedtome.
Sign this application. ThepersonwhofilledoutStep1shouldsignthisapplication.Ifyou’reanauthorizedrepresentative,you
maysignhereaslongasyouhaveprovidedtheinformationrequiredinAppendixC.
Signature
STEP 5
Date(mm/dd/yyyy)
Mail completed application.
Mailyoursignedapplicationto:
Health Insurance Marketplace
1005 XYZ Drive
Washington, DC 20005
What happens next?
We’llfollowupwithyouwithin1–2weeks.You’llgetinstructionsonhowtotakethenextstepstogetyourhealthcoverage.Ifyou
don’thearfromuswithin2weeks,visitHealthCare.govorcall1-800-XXX-XXXX.
Ifyouwanttoregistertovote,youcancompleteavoterregistrationformatXXXXX.gov.
PRA Disclosure Statement
AccordingtothePaperworkReductionActof1995,nopersonsarerequiredtorespondtoacollectionofinformationunlessitdisplaysavalidOMBcontrolnumber.
ThevalidOMBcontrolnumberforthisinformationcollectionis0938-1191.Thetimerequiredtocompletethisinformationcollectionisestimatedtoaverage[Insert
Time(hoursorminutes)]perresponse,includingthetimetoreviewinstructions,searchexistingdataresources,gatherthedataneeded,andcompleteandreview
theinformationcollection.Ifyouhavecommentsconcerningtheaccuracyofthetimeestimate(s)orsuggestionsforimprovingthisform,pleasewriteto:CMS,7500
SecurityBoulevard,Attn:PRAReportsClearanceOfficer,MailStopC4-26-05,Baltimore,Maryland21244-1850.
Page 3 of 3
APPENDIX C
Assistance with Completing this Application
You can choose an authorized representative.
You can give a trusted person permission to talk about this application with us, see your information, and act for you on
matters related to this application, including getting information about your application and signing your application
on your behalf. This person is called an “authorized representative.” If you ever need to change your authorized
representative, contact the Marketplace. If you’re a legally appointed representative for someone on this application,
submit proof with the application.
1. Name of authorized representative (First name, Middle name, Last name)
2. Address
3. Apartment or suite number
4. City
5. State
7. Phone number
(
)
6. ZIP code
–
8. Organization name
9. ID number (if applicable)
By signing, you allow this person to sign your application, get official information about this application, and act for
you on all future matters with this agency.
10. Your signature
11. Date (mm/dd/yyyy)
For certified application counselors, navigators, agents, and brokers only.
Complete this section if you’re a certified application counselor, navigator, agent, or broker filling out this application for
somebody else.
1. Application start date (mm/dd/yyyy)
2. First name, Middle name, Last name, & Suffix
3. Organization name
4. ID number (if applicable)
NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-800-XXX-XXXX. Para obtener una copia de este
formulario en Español, llame 1-800-XXX-XXXX. If you need help in a language other than English, call 1-800-XXX-XXXX and tell the
customer service representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-800-XXX-XXXX.