Form Aca-3 - Massachusetts Application For Health And Dental Coverage And Help Paying Costs - Masshealth Form Page 3
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34Massachusetts Application for Health
and Dental Coverage and Help Paying Costs
1
Step
Person 1. tell us about yourself. Please print clearly.
We need one adult in the household to be the contact person for your application.
1. First name, middle name, last name, and suffix
2. Date of birth
3. What is your e-mail address?
No home address. Note: if you check this box, you must provide a mailing address.
4. Home address
5. Apartment or suite number
6. City
7. State
8. ZIP code
9. County
10. Mailing address
Check if same as home address.
11. Apartment or suite number
12. City
13. State 14. ZIP code
15. County
16. Phone number
17. Other phone number
18. # of people listed on the application
19. What is your preferred spoken or written language (if not English)?
20. Is anyone on this application in prison or jail?
Yes
No
If yes, who? Enter the name here:
foR ENRollMENt ASSiStERS oNly
Complete this section if you are an enrollment assister and are filling out this application for someone else. Navigators must fill out
a Navigator Designation Form if they have not done so already. Certified Application Counselors must fill out a Certified Application
Counselor Designation Form if they have not done so already.
Check one
Navigator
Certified Application Counselor
First name, middle name, last name and suffix
E-mail address
Organization name
Organization identification number
Organization phone number
Page 1
ACA-3 (Rev. 10/16)
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