Fillable 2012 Application & Renewal Form printable pdf download

Medicaid for

Connecticut Pre-Existing

Application

and

Low-Income

Condition Insurance Plan

Renewal Form

Adults

This application is for individuals and families who only need health insurance.

If you need other types of assistance for your family, call INFOLINE at 2-1-1. Deaf and hearing-impaired individuals may use a TDD/TTY by calling

1-800-410-1681. Questions, concerns, complaints, or requests for information in alternative formats must be directed to 1-800-842-1508.

If you have any questions about this application or need help completing it, call 1-800-656-6684.

If the information you have does not fit on this form, please attach separate sheets of paper as needed.

Section A: I want health insurance for: (Check (√) the category or categories that match your situation.)

Myself because I am age 19 or older.

Myself because I am pregnant. My due date is: ______________________.

My children under age 19 who do not live with me. I am under a court order to provide

My spouse (or other parent of my children who lives with me).

medical support. This is the address of my children: ________________________.

My children under age 19 who live with me.

I would like to apply for Family Planning coverage (e.g. birth control, sterilization and

Children in my care who live with me and are under the age of 19.

treatment for sexually transmitted diseases)

Section B: Applicant Information - Tell us about yourself.

Client ID

Last Name

First Name

Maiden Name

Day Phone Number

Evening Phone Number

Street Address

City

State

Zip Code

Date of Birth

Mailing Address (If different)

Gender

Male

Female

Are You a US Citizen?

Are you Hispanic

What Language Do You

Race–(Check all that apply)

Social Security Number

(Optional

(Optional if not applying for

or Latino?

Speak Best?

Alaskan Native/Eskimo

Asian

Black or African descent

if not applying for yourself)

Yes

yourself)

Yes

Native American

Pacific Islander

White

Section C: Tell us about the people who need health coverage. Include information about yourself if you want health coverage.

Is this person a

Race (select

First Name

Relation-

Social

US Citizen?

Has Earnings

parent of at

Date of

Gender

Hispanic or

from the

Last Name

and

ship to the

Security

If No, fill out

or other

least one of the

Birth

M/F

Latino?

above

Middle Initial

applicant

Number

Section

Income

children

categories)

Yes

If anyone listed in Section C is pregnant Please list the person’s name and the date that the baby is due:

Does anyone listed receive SSI or have a disability?

Yes

No If yes, list name of person:

Is anyone listed legally blind?

Yes

No If yes, list name of person:

Does anyone listed here have a pre-existing medical condition?

Yes

No If yes, list name of person(s):

W-1HUS (Revised 2/2012)

If you have any questions about this application or need help completing it, call 1-800-656-6684.

2012 Application & Renewal Form

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