Dch Form 1426 – Fill Out and Use This PDF

Application for Health Coverage & Help Paying Costs

www.healthcare.gov

DCH-1426 (Rev. 3-20) Previous edition obsolete

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(We need one adult in the family to be the contact person for your application.)

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:
	17. Preferred spoken or written language (if not English)

STEP 2 Tell us about your family.

Who do you need to include on this application?

Complete the Step 2 pages for every person in your family and household, even if the person has health coverage already. The information in this application helps us make sure everyone gets the best coverage they can. The amount of help or type of program you qualify for is based on the number of people in your family and their incomes. If you don’t include someone, even if they already have health coverage, your eligibility could be affected.

For adults who need coverage:

Include these people even if they aren’t applying for health coverage themselves:

•Any spouse

•Any son or daughter under age 21 they live with, including stepchildren

•Any other person on the same federal income tax return (Including any children over age 21 that are claimed on a parent’s tax return). You don’t need to file taxes to get health coverage.

For children under age 21 who need coverage:

Include these people even if they aren’t applying for health coverage themselves:

•Any parent (or stepparent) they live with

•Any sibling they live with

•Any son or daughter they live with, including stepchildren

•Any other person on the same federal income tax return. You don’t need to file taxes to get health coverage.

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.

Complete Step 2 for each person in your family. Start with yourself, then add other adults and children. If you have more than

2 people in your family, you’ll need to make a copy of the pages and attach them. You don’t need to provide immigration status or a Social Security Number (SSN) for family members who don’t need health coverage. We’ll keep all the information you provide private and secure as required by law. We’ll use personal information only to check if you’re eligible for health coverage.

To be eligible for coverage, parents requesting health care coverage for themselves must provide proof that the children have creditable coverage, even if not applying for the children. Credible coverage is health insurance coverage under any of the following: a group health plan; individual health insurance; student health insurance; Medicare; Medicaid; CHAMPUS and TRICARE; The Federal Employees Health Benefits Program; Indian Health Service; The Peace Corps; Public Health Plan (any plan established or maintained by a State, the U.S. government, or a foreign country); Children’s Health Insurance Program (CHIP); or, a state health insurance high risk pool.

DCH-1426 (Rev. 3-20) Previous edition obsolete

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STEP 2: PERSON 1 (Start with yourself)

Complete Step 2 for yourself, your spouse/partner and children who live with you and/or anyone on your same federal income tax return if you file one. See page 1 for more information about who to include. If you don’t file a tax return, remember to still add family members who live with you.

1. First name, Middle name, Last name, & Suffix

2. Relationship to you?

								SELF
3. Date of birth (mm/dd/yyyy)		4.	Gender:		5. Are you married?	Yes	No
			Male	Female	If YES, Spouse name:
6. Do you live with at least one or more child(ren) under the age of 19, and are you the main person taking care of this child?								Yes	No
If Yes, provide child(ren) names and relationship to you:
7. Are you a full-time student?	Yes		No

8. Did you consume water from the Flint Water System and live, work or receive childcare or education at an address that was served by the Flint Water

System from April 2014 through present day?			Yes		No If yes, complete Appendix D.
9. Are you under 21?	Yes	No If YES, provide parent names
Mother's Name:								Father's Name:
10. Social Security Number (SSN)			-		-

We need this if you want health coverage and have an SSN. Providing your SSN can be helpful if you don’t want health coverage too since it can speed up the application process. We use SSNs to check income and other information to see who’s eligible for help with health coverage costs. If someone wants help getting an SSN, call 800-772-1213 or visit socialsecurity.gov. TTY users should call 800-325-0778.

11.Do you plan to file a federal income tax return NEXT YEAR?

(You can still apply for health insurance even if you don’t file a federal income tax return.)

YES. If yes, please answer questions a–c.							NO. If no, skip to question c.
a. Will you file jointly with a spouse?					Yes	No
If yes, name of spouse:
b. Will you claim any dependents on your tax return?						Yes	No
If yes, list name(s) of dependents:
c. Will you be claimed as a dependent on someone’s tax return?							Yes	No
If yes, please list the name of the tax filer:
How are you related to the tax filer?					_______________________________________________________
12. Are you pregnant now/last three months?					Yes	No If yes, how many babies are expected this pregnancy?
Due Date/end date?

13.Do you need health coverage?

(Even if you have insurance, there might be a program with better coverage or lower costs.)

YES. If yes, answer all the questions below. NO. If no, skip to the income questions on page 4. Leave the rest of this page blank.

13a.	Were you in foster care in Michigan at age 18 or older?		Yes	No
14.	Do you have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc), live
	in a medical facility or nursing home, or are you medically frail?			Yes	No
15. Are you a U.S. citizen or U.S. national?		Yes		No

16.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.

a. Immigration document type

b. Document ID number

c. Have you lived in the U.S. since 1996?

Yes

No

d. Are you, or your spouse or parent a veteran or an active-duty

member of the U.S. military?

Yes

No

e. U.S. entry date

17. Do you want help paying for medical bills from the last 3 months?

Yes

No

Which month(s)

18. If Hispanic/Latino, ethnicity (OPTIONAL - check all that apply.)

Mexican

Mexican American

Chicano/a

Puerto Rican

Cuban

Other

19. Race (OPTIONAL - check all that apply.)

White

American Indian or

Filipino

Other Asian

Samoan

Black or African

Alaska Native

Japanese

Native Hawaiian

Other Pacific Islander

American

Asian Indian

Korean

Guamanian or

Other

Chinese

Vietnamese

Chamorro

DCH-1426 (Rev. 3-20) Previous edition obsolete

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