CCFRM604 Form: Covered California Application for Health Insurance

Choose one adult in the family to be the Primary Contact, to contact if more information is needed. The Primary Contact must be 18 years or older.

Common mistake: You must list the Primary Contact as Person 1 throughout the application.

Write the Primary Contact's first name, middle name, last name and suffix. Check Phone, Mail or Email as the best way to contact you.

To tell about more than 4 people, make a copy of pages 5-14 before you fill them out. Send the added pages with your application. Read down the column to tell about Persons 1, 2, 3, and 4. Keep each person in the same column on all of the pages.

Write the first name, middle name, last name and suffix of each person in your home.

Common mistake: Do not list a P.O. Box as the home address. You must give a mailing address if you do not have a home address.

Fill out Part 4 for anyone who wants to apply for health coverage. Check yes if this person wants to apply for Medi-Cal or Covered California.

If yes, answer the rest of the questions on this page and all questions on page 11 for each person applying for coverage.

Social Security number (SSN): If you are not applying for coverage for yourself, you do not have to give your SSN. However, if you are the primary tax filer applying for financial help for members of your tax household, Covered California needs your SSN to see if they qualify for financial help with Covered California. Tell each person's SSN if they have one and are applying.

You only need to provide this information for people in your family who are applying for health insurance.

If you answered yes to either citizenship question, skip to Part 6: Tax information on page 14. If you answered no, answer the questions on page 13.

Tell about this person's immigration status and immigration document, if they have one. Then fill in the boxes.

Tax information is required for everyone in your household even if they are not filing taxes. If you don't plan to file taxes, you may still qualify for free or low-cost insurance. You must still answer the questions in Tax information.

If this person plans to file taxes, check only one tax filing status box. If you are married filing jointly, you must include your spouse on this application, beginning on page 5.

Common mistake: Which person is the primary tax filer? This person's name is first on the tax return. Only one person on this application can be the primary tax filer. Please enter their name even if they are not listed on the application. Please write “none” if you don't file taxes.

Fill out pages 15-16 for each person in your household who has income even if they aren't applying for health coverage. Tell about any current income that you get, and all income starting January 1 of this year. This can be from a job, self-employment, or any other income.

Employment: If you have a job, list the amount of income you get before taxes. This is the gross amount. Self-employment: If you are self-employed, list your net income from self-employment. Social Security or interest income: If you get Social Security benefits or interest income, list your gross income.

Does anyone on this application have income? If yes, tell about all income starting on January 1 of this year, for all people listed on this application. Tell about their income even if they are not applying for health coverage.

Fill out the Deductions page if anyone in your household has deductions on their taxes even if they aren't applying for health coverage. Deductions are amounts subtracted from income on a federal tax return for certain expenses.

Only fill out the authorized representative page if you want to choose someone to help with your health care case. If you choose an authorized representative, this person or organization is allowed to act on your behalf for your Covered California or Medi-Cal case.

Sign and date there if you have chosen an authorized representative.

Remember to sign your application. You certify (or declare) under penalty of perjury, under the laws of the State of California, that it is true and correct.

Under California Penal Code Section 126, perjury is punishable by imprisonment for up to 4 years. You may be fined up to $25,000 if you negligently, or with intentional disregard for the rules, provide false information in your application (checked October 19, 2026). You may be fined up to $250,000 if you knowingly lie on your application (checked October 19, 2026).

The applicant or authorized representative signs and dates the application.

If you don't have all the information needed to complete this application, please call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500) so you can be guided through it. Or, sign and send in your application anyway. Covered California will help you finish your application. This help is always free.

You can use this form to register to vote.

Fill out Attachment A if anyone in your household had any qualifying life events. You do not need a qualifying life event for Medi-Cal.

Fill out Attachment B if anyone on this application has other health insurance or an offer of other health insurance.

Fill out Attachment C if anyone on this application wants to choose a health or dental plan. If you are eligible through Covered California, you can use this form to choose health insurance plans.

Fill out Attachment E if anyone in your household has a job. If you think you will qualify for Medi-Cal, you do not need to fill out Attachment E.

You can apply for free or low-cost health care through Medi-Cal or Covered California at any time of the year; to enroll in a health plan through Covered California, you must apply during the open enrollment period, or you must have a qualifying life event to enroll during a special enrollment period.

Mail your signed application to: Covered California P.O. Box 989725 West Sacramento, CA 95798-9725. Or fax your signed application to: 1-888-329-3700.

If you already have Medi-Cal or a Covered California plan and need to report a change, do not use this application. If you had Medi-Cal during your pregnancy and you are only applying for your baby, you do not need to fill out this application if your baby is younger than 1 year old.