Application For Health Coverage & Help Paying Costs (Short Form) Page 4

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STEP 4

Read & sign this application.

•

I’m signing this application under penalty of perjury, which means I’ve provided true answers to all the questions on this form to

the best of my knowledge. I know that I may be subject to penalties under federal law if I intentionally provide false or untrue

information.

•

I know that I must tell Maryland

Health Connection if anything changes (and is dif

ferent than) what I wrote on this application.

I can visit

MarylandHealthConnection.gov

or call 1-855-642-8572

to report any changes. I understand that a change in my

information could a ect my eligibility.

•

I know that under federal law, discrimination isn’t permitted on the basis of race, color, national origin, sex, age, sexual

orientation, gender identity, or disability. I can ﬁle a complaint of discrimination by visiting

•

I conﬁrm that I’m not incarcerated (detained or jailed).

•

I conﬁrm that next year I expect to ﬁle a federal income tax return, won’t claim dependents on that return, and can’t be claimed as

a dependent on anyone else’s federal income tax return.

•

I conﬁrm that I’m not o ered health coverage from an employer.

We need this information to check your eligibility for help paying for health coverage if you choose to apply. We’ll check your answers

using information in our electronic databases and databases from the Internal Revenue

Service (IR S), Social Security, the Department

of Homeland Security, and/or a consumer reporting agency. If the information doesn’t match, we may ask you to send us proof.

Renewal of coverage in future years

To make it easier to determine my eligibility for help paying for health coverage in future years, I agree to allow the marketplace to

use income data, including information from tax returns. The marketplace will send me a notice, let me make any changes, and I can

opt out at any time.

Yes, renew my eligibility automatically for the next

5 years (the maximum number of years allowed), or for a shorter number of years:

4 years

3 years

2 years

1 year

Don’t use information from tax returns to renew my coverage.

If I’m eligible for Medicaid

If I enroll in Medicaid, I’m giving the Medicaid agency my rights to pursue and get any money from other health insurance, legal

settlements, or other third parties.

My right to appeal

If I think Maryland Health Connection or Medicaid/Maryland Children’s

Health Program (MC HP) has made a mistake, I can appeal its

decision. To appeal means to tell someone at Maryland

Health Connection or Medicaid/MC

HP that I think the action is wr ong, and ask

for a fair review of the action. I know that I can ﬁnd out how to appeal by contacting the marketplace at

1-855-642-8572 . I know that

I can be represented in the process by someone other than myself. My eligibility and other important information will be explained

to me.

Sign this application.

The person who ﬁlled out

Step 1 should sign this application. If you’r

e an authorized representative, you may

sign here as long as you have provided the information required in Appendix C.

Signature

Date (mm/dd/yyyy)

STEP 5

Mail completed application.

Mail your signed application to:

O ce of Eligibility Services

Maryland Health Connection

P.O. Box 857

PO Box 386

Lanham, MD 20703-0857

Baltimore, MD 21203-0386

What happens next?

We’ll follow up with you within 1–2 weeks. You’ll get instructions on how to take the next steps to get your health coverage. If you

don’t hear from us within 2 weeks, visit

MarylandHealthConnection.gov

or call 1-855-642-8572 .

If you want to register to vote, you can complete a voter registration form at

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid

O MB contr ol number.

The valid O MB contr ol number for this information collection is 0938-1191. The time required to complete this information collection is estimated to average 15 minutes

per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you

have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CM

S, 7500 Security Boulevar d, Attn: PRA Reports

Clearance O fficer, Mail Stop C4-26-05, Baltimor e, Maryland 21244-1850.

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