Application for Health and Dental Insurance Coverage

Application for
Health and Dental
Insurance Coverage
Who can use this
application?
Use this application for youself and anyone in your tax household who
needs health or dental insurance coverage. People in your tax household
could include a spouse, child under the age of 27, or a child over the age
of 26 if they have a disability.
Apply faster online.
Apply faster online at MAhealthconnector.org.
Get help with
this application:
ƒƒ Visit MAhealthconnector.org.
ƒƒ Call our Customer Service at 1-877 MA ENROLL (1-877-623-6765) or
TTY: 1-877-623-7773.
ƒƒ In person: there may be counselors in your area who can help.
Visit MAhealthconnector.org for more information.
ƒƒ En Español: Llame a nuestro centro de ayuda gratis al
1-877 MA ENROLL (1-877-623-6765).
ƒƒ If you need help in a language other than English, call 1-877 MA ENROLL
(1-877-623-6765) and tell the Customer Service Representative the
language you need. We’ll get you help at no cost to you.
If someone is helping you fill out this application, you may need
to complete Appendix A.
Sending the application:
Send your complete, signed application to:
Massachusetts Health Connector
133 Portland Street, 1st Floor
Boston, MA 02114-1707
or fax to 877-623-2155.
Filling out this application doesn’t mean you have to buy health coverage.
Get help paying
for insurance:
You need to use a different application to get help with costs.
You could qualify for:
ƒƒ A new tax credit that can help pay your premiums for health
insurance coverage.
ƒƒ Free or low-cost health insurance plan from Medicaid or the
Children’s Health Insurance Program (CHIP). You may qualify for a
free or low-cost program even if you earn as much as $94,200 a
year (for a family of 4). Visit MAhealthconnector.org to learn more.
If you’re not sure what you qualify for, go to MAhealthconnector.org
and apply online.
Questions?
Visit MAhealthconnector.org or call 1-877 MA ENROLL (1-877-623-6765)
or TTY: 1-877-623-7773, Monday to Friday, 8:00 a.m. to 6:00 p.m.
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STEP 1
PERSON 1
Tell us about yourself.
Choose one adult in the family to be the contact person for your application.
Please be sure to answer all questions and fill out all parts of this application.
First name
Middle name
Home address (Not PO box)
Last name
Unit or apartment number
Check here  if you are homeless.
City
State
Mailing address
ZIP code
Unit or apartment number
Check here  if same as home address.
City
State
Best phone number
 Home  Work  Cell
Suffix
Other phone number
ZIP code
 Home  Work  Cell
Email address:
Do you want to get information about this application by email?
Language you prefer to speak (if not English)
 Yes
 No
Language you prefer to write (if not English)
o you need health coverage?  Yes  No
D
Do you need dental coverage?  Yes  No
If yes, have you had dental insurance within the last 12 months?  Yes  No
If you need health or dental coverage, answer all the questions below. If not, go to Step 2 on page 3.
Social Security number (SSN): ___ ___ ___ /___ ___ /___ ___ ___ ___
We need Social Security numbers (SSNs) for anyone who wants coverage. We use SSNs to verify
citizenship. If someone doesn’t have an SSN, visit socialsecurity.gov or call 1-800-772-1213.
Are you
Date of birth (month/day/year)
 Male  Female
Are you a U.S. citizen or U.S. national?
 Yes
 No
If you are not a U.S. citizen or U.S. national, are you lawfully present in the U.S.?  Yes  No
If yes, write your immigration document type_______________________________________________________
For more information on acceptable immigration documents, go to MAhealthconnector.org
and write your immigration document ID number______________________________________________________________
Are you living in Massachusetts?  Yes  No
If yes, do you plan to stay in Massachusetts?  Yes  No
If no, are you planning to move to Massachusetts?  Yes  No
Are you in jail or prison?  Yes  No If yes, are you (check one below)
 Convicted. What is your expected release date? (month/day/year) ___ ___ /___ ___ /___ ___ ___ ___
 Not convicted. (For example: confined only, awaiting trial)
Questions?
Visit MAhealthconnector.org or call 1-877 MA ENROLL (1-877-623-6765)
or TTY: 1-877-623-7773, Monday to Friday, 8:00 a.m. to 6:00 p.m.
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STEP 2
Tell us about anyone else who needs health or dental insurance coverage.
If you have more than 4 people to include, make a copy of this page.
PERSON 2
First name
Middle name
Last name
Social Security number (SSN)
Suffix
Date of birth (month/day/year)
Does Person 2 have the same home and mailing address as Person 1?
Relationship to Person 1
Is Person 2
 Male?  Female?
 Yes
 No If no, list address:
Home address (Not PO box)
Unit or apartment number
City
State
Mailing address
ZIP code
Unit or apartment number
Check here  if same as home address.
City
State
ZIP code
oes Person 2 need health coverage?  Yes  No
D
Does Person 2 need dental coverage?  Yes  No
If yes, has Person 2 had dental insurance within the last 12 months?  Yes  No
If Person 2 needs health or dental coverage, answer all the questions below. If not, go to Person 3 or Step 3.
Is Person 2 a U.S. citizen or U.S. national?
 Yes
 No
If Person 2 is not a U.S. citizen or U.S. national, is he or she lawfully present in the U.S.?
 Yes
 No
If yes, write the immigration document type________________________________________________________
For more information on acceptable immigration documents, go to MAhealthconnector.org
and write the immigration document ID number_______________________________________________________________
Is Person 2 living in Massachusetts?  Yes  No
If yes, does he or she plan to stay in Massachusetts?  Yes
If no, does he or she plan to move to Massachusetts?  Yes
Is Person 2 in jail or prison?
 Yes
 No
 No
 No
If yes, is he or she (check one below)
 Convicted. What is your expected release date? (month/day/year)  Not convicted. (For example: confined only, awaiting trial)
Questions?
___ ___ /___ ___ /___ ___ ___ ___
Visit MAhealthconnector.org or call 1-877 MA ENROLL (1-877-623-6765)
or TTY: 1-877-623-7773, Monday to Friday, 8:00 a.m. to 6:00 p.m.
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STEP 2
Tell us about anyone else who needs health or dental insurance coverage.
(continued)
PERSON 3
First name
Middle name
Last name
Social Security number (SSN)
Suffix
Date of birth (month/day/year)
Does Person 3 have the same home and mailing address as Person 1?
Relationship to Person 1
Is Person 3
 Male?  Female?
 Yes
 No If no, list address:
Home address (Not PO box)
Unit or apartment number
City
State
Mailing address
ZIP code
Unit or apartment number
Check here  if same as home address.
City
State
ZIP code
oes Person 3 need health coverage?  Yes  No
D
Does Person 3 need dental coverage?  Yes  No
If yes, has Person 3 had dental insurance within the last 12 months?  Yes  No
If Person 3 needs health or dental coverage, answer all the questions below. If not, go to Person 4 or Step 3.
Is Person 3 a U.S. citizen or U.S. national?
 Yes
 No
If Person 3 is not a U.S. citizen or U.S. national, is he or she lawfully present in the U.S.?
 Yes
 No
If yes, write the immigration document type________________________________________________________
For more information on acceptable immigration documents, go to MAhealthconnector.org
and write the immigration document ID number_______________________________________________________________
Is Person 3 living in Massachusetts?  Yes  No
If yes, does he or she plan to stay in Massachusetts?  Yes
If no, does he or she plan to move to Massachusetts?  Yes
Is Person 3 in jail or prison?
 Yes
 No
 No
 No
If yes, is he or she (check one below)
 Convicted. What is your expected release date? (month/day/year)  Not convicted. (For example: confined only, awaiting trial)
Questions?
___ ___ /___ ___ /___ ___ ___ ___
Visit MAhealthconnector.org or call 1-877 MA ENROLL (1-877-623-6765)
or TTY: 1-877-623-7773, Monday to Friday, 8:00 a.m. to 6:00 p.m.
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STEP 2
Tell us about anyone else who needs health or dental insurance coverage.
(continued)
PERSON 4
First name
Middle name
Last name
Social Security number (SSN)
Suffix
Date of birth (month/day/year)
Does Person 4 have the same home and mailing address as Person 1?
Relationship to Person 1
Is Person 4
 Male?  Female?
 Yes
 No If no, list address:
Home address (Not PO box)
Unit or apartment number
City
State
Mailing address
ZIP code
Unit or apartment number
Check here  if same as home address.
City
State
ZIP code
oes Person 4 need health coverage?  Yes  No
D
Does Person 4 need dental coverage?  Yes  No
If yes, has Person 4 had dental insurance within the last 12 months?  Yes  No
If Person 4 needs health or dental coverage, answer all the questions below. If not, go to Step 3.
Is Person 4 a U.S. citizen or U.S. national?
 Yes
 No
If Person 4 is not a U.S. citizen or U.S. national, is he or she lawfully present in the U.S.?
 Yes
 No
If yes, write the immigration document type________________________________________________________
For more information on acceptable immigration documents, go to MAhealthconnector.org
and write the immigration document ID number_______________________________________________________________
Is Person 4 living in Massachusetts?  Yes  No
If yes, does he or she plan to stay in Massachusetts?  Yes
If no, does he or she plan to move to Massachusetts?  Yes
Is Person 4 in jail or prison?
 Yes
 No
 No
 No
If yes, is he or she (check one below)
 Convicted. What is your expected release date? (month/day/year)  Not convicted. (For example: confined only, awaiting trial)
Questions?
___ ___ /___ ___ /___ ___ ___ ___
Visit MAhealthconnector.org or call 1-877 MA ENROLL (1-877-623-6765)
or TTY: 1-877-623-7773, Monday to Friday, 8:00 a.m. to 6:00 p.m.
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STEP 3
American Indian or Alaska Native (AI/AN) family members
Are you or is anyone in your family an American Indian or Alaska Native?
 Yes If yes, continue. If you have more people to include, make a copy of this page and attach.
 No If no, go to Step 4.

AI/AN Person 1
First name
Middle name
Member of a federally recognized tribe?
 Yes  No

Last name
Suffix
If yes, tribe name
AI/AN Person 2
First name
Middle name
Member of a federally recognized tribe?
 Yes  No
STEP 4
Last name
Suffix
If yes, tribe name
Read and sign this application.
ƒƒ I know that I am signing this application under penalty of perjury, which means I’ve provided
true answers to all of the questions 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.
ƒƒ I know that I must tell the Massachusetts Health Connector if anything changes and is
different from what I wrote on this application. I can visit MAhealthconnector.org or call
1-877 MA ENROLL (1-877-623-6765) to report any changes. I understand that a change in my
information could mean that other members of my household no longer qualify for coverage.
ƒƒ I know that under federal law, discrimination is not 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 www.hhs.gov/ocr/office/file.
ƒƒ I know that the information on this form will only be used to see if I, and others on the application,
qualify for health or dental insurance coverage and will be kept private, as required by law.
ƒƒ I understand that my information will be used to check my qualifications for health or dental
coverage. The Connector will check my answers using information in electronic databases such
as the Social Security Administration and Department of Homeland Security databases. If the
information doesn’t match, I may need to send proof.
ign this application.
S
The person who filled 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 A.
Signature
Questions?
Date (month/day/year)
Visit MAhealthconnector.org or call 1-877 MA ENROLL (1-877-623-6765)
or TTY: 1-877-623-7773, Monday to Friday, 8:00 a.m. to 6:00 p.m.
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STEP 5
Mail completed application.
ƒƒ Mail your signed application to:
Massachusetts Health Connector
133 Portland Street, 1st Floor
Boston, MA 02114-1707
FAX: (877) 623-2155
Appendix A
Get help completing this application.
You can choose an authorized representative.
You can give a trusted person permission to talk about this application with us, see your information, and
act for you on matters related to this application, including getting information about your application and
signing your application on your behalf. This person is called an “authorized representative.” If you would
like to have an authorized representative, download the Authorized Representative Designation (ARD) Form
from our website at MAhealthconnector.org or call Customer Service at 1-877-MA ENROLL.
For Certified Application Counselors, Navigators, and Brokers only
Complete this section if you’re filling out this application for somebody else. Navigators must fill out a
Navigator Designation Form if you have not done so already. Brokers and Certified Application Counselors,
please fill out a separate ARD/PSI Form if you do not already have one on file with the Health Connector.
Date (month/day/year)
First name
Middle name
Last name
Suffix
Organization name
Questions?
Visit MAhealthconnector.org or call 1-877 MA ENROLL (1-877-623-6765)
or TTY: 1-877-623-7773, Monday to Friday, 8:00 a.m. to 6:00 p.m.
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