Application For Health Coverage & Help Paying Costs (Short Form) Page 2

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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.

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STEP 1

Tell us about yourself.

1. First name, Middle name, Last name, & suffix

2. home address (Leave blank if you don’t have one.)

3. Apartment or suite number

4. City

5. state

6. Zip code

7. County

8. Mailing address (if different from home address)

9. Apartment or suite number

10. City

11. state

12. ZIP code

13. County

14. Phone number

15. other phone number

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16. Do you want to get information about this application by email?

Yes

Email address:

17. What is your preferred spoken or written language (if not English)?

18. Date of birth (mm/dd/yyyy)

19. sex

Male

Female

20. social security number (ssn)

We need this if you want health coverage and have an SSN. We use ssns to check income and other information to see if you’re eligible for help

with health coverage costs. If you need help getting an ssn, call 1-800-772-1213 or visit socialsecurity.gov. TTY users should call 1-800-325-0778.

21. Are you a U.s. citizen or U.s. national?

Yes

22. 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 ID number below.

a. Immigration document type

b. Document ID number

c. have you lived in the U.s. since 1996?

Yes

d. Are you a veteran or an active-duty member of the U.s. military?

Yes

23. Are you pregnant?

Yes

If yes, how many babies are expected during this pregnancy?

24. Do you have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc.) or

live in a medical facility or nursing home?

Yes

25. If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.)

Mexican

Mexican American

Chicano/a

Puerto Rican

Cuban

other

26. Race (OPTIONAL—check all that apply.)

White

American Indian or