Application For Health Coverage & Help Paying Costs (Short Form) Page 3
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1
2
3
4STEP 2
Current job & income information
Employed – If you’re currently employed, tell us about your income. start with question 1.
Not Employed – skip to question 11.
Self Employed – skip to question 10.
CURRENT JOB 1:
/
/
Job start date:
1. Employer name and address
2. Employer phone number
3. Average hours worked each week
(
)
–
4. Wages/tips (before taxes)
hourly
Weekly
Every 2 weeks
Twice a month
Monthly
Yearly
$
CURRENT JOB 2:
/
/
Job start date:
(If you have more jobs and need more space, attach another sheet of paper.)
5. Employer name and address
6. Employer phone number
7. Average hours worked each week
(
)
–
8. Wages/tips (before taxes)
hourly
Weekly
Every 2 weeks
Twice a month
Monthly
Yearly
$
9. In the past year, did you:
Change jobs
stop working
start working fewer hours
none of these
10. If self-employed, answer the following questions:
a. Type of work
b. how much net income (profits once business expenses are paid) will
you get from this self-employment this month?
$
OTHER INCOME THIS MONTH:
11.
Check all that apply, and give the amount and how often you get it.
NOTE: You don’t need to tell us about child support, veteran’s payment, or supplemental security Income (ssI).
Retirement accounts
$
how often?
none
Alimony received
$
how often?
Unemployment
$
how often?
net farming/fishing
$
how often?
Pensions
$
how often?
other income
$
how often?
social security
$
how often?
Type:
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, how much
how often?
NO.
YEARLY INCOME:
13.
Complete only if your income changes from month to month. If you don’t expect changes to your monthly income, skip
to step 3.
Your total income this year
Your total income next year (if you think it will be different)
$
$
STEP 3
Your health coverage
1. Are you enrolled in health coverage now from any of the following?
YES.
If yes, check which coverage you have.
NO.
Medicaid
VA health care programs
MChP
other
Medicare
name of health insurance
TRICARE (don’t check if you have Direct
Care or Line of Duty)
Peace Corps
Policy number
NEED HELP WITH YOUR APPLICATION?
Visit
MarylandHealthConnection.gov
or call us at 1-855-642-8572. Para obtener una copia de este
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.
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