Application For Health Coverage & Help Paying Costs (Short Form)
Download a blank fillable Application For Health Coverage & Help Paying Costs (Short Form) in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Application For Health Coverage & Help Paying Costs (Short Form) with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4Application for Health Coverage
& Help Paying Costs (Short Form)
Use this application
• Affordable private health insurance plans that offer comprehensive
coverage to help you stay well
to see what coverage
• A new tax credit that can immediately help pay your premiums for health
you qualify for
coverage
• Free or low-cost insurance from Medicaid or the Maryland Children’s health
Program (MChP)
Who can use this
single adults who:
• Aren’t offered health coverage from their employer
application?
• Don’t have any dependents and can’t be claimed as a dependent on
someone else’s tax return
NOTE: If any of the following apply, you need to fill out a different form to
make sure you get the most benefits possible:
• You’re married or have dependent children.
• You were in the foster care system, and you’re under age 26.
• You have items that can be deducted from your income. If your only
deduction is student loan interest, you can use this form.
• You’re American Indian or Alaska native.
Apply faster
Apply faster online at MarylandHealthConnection.gov.
online
What you may
• Your social security number (or document number if you’re a legal
immigrant)
need to apply
• Employer and income information (for example, from paystubs,
W-2 forms, or wage and tax statements)
Why do we ask for
We ask about income and other information to let you know what coverage
you qualify for and if you can get any help paying for it.
this information?
We’ll keep all the information you provide private and secure, as required
by law. To view the Privacy Act statement, go to
MarylandHealthConnection.gov.
What happens
send your complete, signed application to the address on page 3. If you
don’t have all the information we ask for, sign and submit your application
next?
anyway. We’ll follow up with you within 1–2 weeks. Filling out this application
doesn’t mean you have to buy health coverage.
Get help with this
• Online: MarylandHealthConnection.gov.
• Phone: Call our consumer support center at 1-855-642-8572.
application
• In person: There may be counselors in your area who can help.
Visit MarylandHealthConnection.gov, or call 1-855-642-8572 for more
information.
• En Español: Llame a nuestro centro de ayuda gratis al
1-855-642-8572.
NEED HELP WITH YOUR APPLICATION?
MarylandHealthConnection.gov
or call us at 1-855-642-8572. Para obtener una copia de este
Visit
formulario en Español, llame 1-855-642-8572. If you need help in a language other than English, call 1-855-642-8572 and tell the customer service
representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-855-642-8573.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical