Dhhs Form 3400 - Application For Medicaid And Affordable Health Coverage
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16Application for Medicaid
and Affordable Health
Coverage
South Carolina Department of Health and Human Services
•
Affordable private health insurance plans that offer
comprehensive coverage to help you stay well.
Use this application
•
A new tax credit that can immediately help pay your premium for
to see what
health coverage.
coverage choices
•
Free or low-cost insurance from Medicaid or the Children’s Health
you qualify for
Insurance Program (CHIP).
You may qualify for a free or low-cost program even if you
earn as much as $94,000 a year (for a family of 4).
Apply faster online
•
Apply faster online at SCDHHS.gov or HealthCare.gov.
Social Security Numbers (or document numbers for any
•
legal immigrants who need insurance)
• Employer and income information for everyone in your
What you may
family (for example, from paystubs, W-2 forms, or wage and
tax statements)
need to apply
• Policy numbers for any current health insurance
• Information about any job-related health insurance available
to your family
We ask about income and other information to let you know
what coverage you qualify for and how to get any help paying
Why do we ask for
for it. We’ll keep all the information you provide private
this information?
and secure, as required by law. To view the Privacy Act
Statement, go to https://
SCDHHSNoticeofPrivacyPractices080107.pdf.
Send your complete, signed application to the address on page
13.
If you don’t have all the information we ask for, sign and
submit your application anyway. We’ll follow-up with you
within 1–2 weeks. You’ll get instructions on the next steps to
What happens next?
complete your application for health coverage. If you don’t hear
from us, visit SCDHHS.gov or call 1-888-549-0820.
Filling out this application doesn’t mean you have to buy health
coverage.
NEED HELP WITH YOUR APPLICATION?
SCDHHS.gov
or call us at 1-888-549-0820. Para obtener una copia de este formulario
Visit
en Español, llame 1-888-549-0820. If you need help in a language other than English, call 1-888-549-0820 and tell the customer service
representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-888-842-3620.
DHHS Form 3400 (June 2016)
Application for Medicaid and Affordable Health Coverage
Page 1 of 13
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