Dhhs Form 3400 - Application For Medicaid And Affordable Health Coverage Page 2
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16• Use this application to apply for anyone in your family.
• Apply even if you or your child already has health coverage.
You could be eligible for lower-cost or free coverage.
• If you’re single, you may be able to use a short form.
Visit HealthCare.gov.
Who can use this
• Families that include immigrants can apply. You can apply
for your child even if you aren’t eligible for coverage.
application?
Applying won’t affect your immigration status or chances of
becoming a permanent resident or citizen.
• If someone is helping you fill out this application, you may
need to complete the Authorized Representative Form
(1282), which can be downloaded at SCDHHS.gov.
Who do you need to include on this application?
Tell us about all the family members who live with you.
If you file taxes, we need to know about everyone on
your tax return. (You don’t need to file taxes to get
health coverage.)
DO include:
• Yourself
• Your spouse
• Your children under 21 who live with you
• Your unmarried partner who needs health
coverage
Tell us about
• Anyone you include on your tax return, even if
yourself
they don’t live with you
• Anyone else under 21 who you take care of
and your family.
and lives with you
You DON’T have to include:
• Your unmarried partner who doesn’t need
health coverage
• Your unmarried partner’s children
• Your parents who live with you, but file their
own tax return (if you’re over 21)
• Other adult relatives who file their own tax
return
The amount of assistance or type of program you qualify for
depends on the number of people in your family and their
incomes. This information helps us make sure everyone gets
the best coverage they can.
• Online:
SCDHHS.gov
• Phone: Call our Help Center at 1-888-549-0820.
• In person: There may be counselors in your area who can
help.
Get help with this
Visit our website or call 1-888-549-0820 for more
application
information.
• En Español: Llame a nuestro centro de ayuda gratis al
1-888-549-0820.
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 2 of 13
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