Application for Health Coverage & Help Paying Costs (Short Form)

The OMB No. 0938-1191 is an application short form for health coverage which can be of help for the insured. Download

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Form  Approved 
OMB  No. 0938-1191 	
Application for Health Coverage & Help Paying Costs (Short Form) 	
THINGS TO KNOW 	
Use this applicatio
to see what 
coverage you  
qualify for 
Who can use this 
 application? 
Apply faster   
online 
What you may   
need to apply 
Why do we ask for 
this information? 
What happens  
next? 
Get help with this 
application  n 
NEED HELP WITH YOUR APPLICATION?	 Visit HealthCare.gov or call us at 1-800-XXX-XXXX . Para obtener una copia de este formulario 
en Español, llame  1-800-XXX-XXXX. If you need help in a language other than English, call  1-800-XXX-XXXX and tell the customer service 
representative the language you need. We’ll get you help at no cost t\
o you. TTY users should call  1-800-XXX-XXXX.

? 	
 		 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
	 	 	 	 	 	 	 	 		  			
 	
 	  
	 				 	 	 				 	 				  	 				
 				
  		
 
 
 	
	 	 	
 	
 		 	 	
	 		
 			
 			
 
 
   
 	
		
 			
 		 		
 
 	
	 		
 			
STEP 1 	Tell us about yourself.
 	
1. 
First  name,  Middle  name, Last name,  & Suffix 
2.  Home  address  (Leave blank if you  don’t  have one.)  3. Apartment  or suite  number 
4.  City  5. State  6. Zip  code  7. County 
8.  Mailing  address  (if different  from home  address)  9. Apartment  or suite  number 
10.  City  11. State  12. ZIP  code  13. County 
14.  Phone  number 
( )  – 	
15. Other  phone  number 
( )  – 	
16. Do you  want  to get  information  about this application  by email? 	Yes 	No 
Email  address: 	
Male 	Female 	
Yes 	No 
22.  If you aren’t a U.S. citizen or U.S. national, do  you have  eligible  immigration  status? 	
Yes. Fill in your  document  type and ID number  below. 	
Yes 	No 
23.  Are you  pregnant? 	
Yes 	No
 
If yes,  how many  babies  are expected  during this pregnancy?
 
24.  Do you  have  a physical,  mental, or emotional  health condition  that causes  limitations  in activities  (like bathing,  dressing,  daily chores,  etc.) 
or  live  in a medical  facility or nursing  home? 	
Yes 	No 
25.  If Hispanic/Latino, ethnicity ( OPTIONAL—check all that apply.) 	
Mexican 	Mexican American 	Chicano/a 	Puerto Rican 	Cuban 	Other 
26.	  Race (OPTIONAL—check all that apply.) 
White 	
American  Indian or 	Filipino 	Vietnamese 	Guamanian  or Chamorro 
Alaska  Native 
Black  or African  Japanese Other Asian 
Samoan 
American  Asian Indian 
Korean Native Hawaiian  Other Paci�c  Islander 
Chinese  Other 	
Page 1 of 3 
NEED HELP WITH YOUR APPLICATION?	 Visit HealthCare.gov or call us at 1-800-XXX-XXXX . Para obtener una copia de este formulario 
en Espa�ol, llame  1-800-XXX-XXXX. If you need help in a language other than English, call  1-800-XXX-XXXX and tell the customer service 
representative the language you need. We�ll get you help at no cost t\
o you. TTY users should call  1-800-XXX-XXXX.

STEP 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: 
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: 	
(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? 	
$ 	
None  Retirement 
accounts  $  How often? 
Unemployment  $ How often?  Alimony 
received  $ How often? 
Pensions  $ How often?  Net 
farming/fishing  $ How often? 
Social  Security  $ How often?  Other 
income  $ How often? 
Type: 	
YES.  If yes,  how much 	$	 	How  often? 	NO. 	
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 
CHIP  VA 
health  care programs 
Other 
Medicare  Name of health  insurance 
TRICARE  (don’t check  if you  have  Direct 
Care  or Line  of Duty) 
Peace  Corps 
Policy number 	
Page 2 of 3 
NEED HELP WITH YOUR APPLICATION?	 Visit HealthCare.gov or call us at 1-800-XXX-XXXX . Para obtener una copia de este formulario 
en Español, llame  1-800-XXX-XXXX. If you need help in a language other than English, call  1-800-XXX-XXXX and tell the customer service 
representative the language you need. We’ll get you help at no cost t\
o you. TTY users should call  1-800-XXX-XXXX.

STEP 4 	Read & sign this application.
 	
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  the Marketplace  or Medicaid/Children’s  Health Insurance  Program (CHIP) has made  a mistake,  I can  appeal  its decision. 
To  appeal  means to tell  someone  at the  Marketplace  or Medicaid/CHIP  that I think  the action  is wrong,  and ask for a fair  review 
of  the  action.  I know  that I can  �nd  out how  to appeal  by contacting  the Marketplace  at 1-800-XXX-XXXX . 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 �lled  out Step  1 should  sign this application.  If you’re  an authorized  representative,  you 
may  sign here  as long  as you  have  provided  the information  required in Appendix  C. 
Signature  Date	 (mm/dd/yyyy) 
Mail	 your	  signed	  application	  to: 	
Health Insurance Marketplace   
1005 XYZ Drive   
Washington, DC 20005 
STEP 5 	Mail completed application.    	
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 HealthCare.gov  or call  1-800-XXX-XXXX . 
If  you  want  to register  to vote,  you can complete  a voter  registration  form at XXXXX.gov. 
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  OMB  control  number. 
The  valid  OMB  control  number  for this  information  collection is 0938-1191.  The time  required  to complete  this information  collection is estimated  to average  [Insert 
Time  (hours  or 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: CMS,  7500 
Security  Boulevard,  Attn: PRA Reports  Clearance  Officer, Mail Stop  C4-26-05,  Baltimore,  Maryland 21244-1850. 
Page 3 of 3

Assistance with Completing this App\ulication
You can choose an au\utho\fized \fep\fesentative\b
You can give a trusted person permission to talk a\fout this a\kpplication with us, see \bour information, and act for \bou on 
matters related to this application, including get\kting information a\fout \bour application and signing \bour application 
on \bour \fehalf. This person is call\ked an “authorized representative.” If \bou ever need to change \bour authorized 
representative, contact the Marketplace. If \bou’re a legall\b appoint\ked representative for someone on this\k application, 
su\fmit proof with the applic\kation.
1. Name of authorized representative (First name, Middle name, Last name)
2. Address3. Apartment or suite num\fer
4. Cit\b                  \k                  \k                  \k                  \k                  \k        5. State6. ZIP code
7. Phone num\fer 
(      )          –	 
8. Organization name 9. ID num\fer (if applica\fle)	
B\b signing, \bou allow this person to sign \bour application, get official information a\fout this application, and act for 
\bou on all future matters with this agenc\b.
10. Your signature11. Date (mm/dd/\b\b\b\b)
Fo\f ce\ftified application counselo\fs, navigato\fs, agents, and b\foke\fs only\b	  	
Complete this section if \k\bou’re a certified application counselor, navigator, agent, or \froker filling out this\k application for  
some\fod\b else.    
1. Application start date (mm/dd/\b\b\b\b)
2. First name, Middle name, Last name, & Suffix
3. Organization name 4. ID num\fer (if applica\fle)
APPENDIX C
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