Health Insurance Application – Fill Out and Use This PDF

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Step 1: Tell us about yourself.

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

Step 2: Tell us about your household.

Who do you need to include on this application?

Complete the Step 2 pages for each person in your 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 household and your household income. If you don’t include someone, even if they already have health coverage, your eligibility results could be affected.

For adults who need coverage:

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

•Any spouse

•Any child under age 21 they live with, including stepchildren

•Any other person on the same federal income tax return (including any children over age 21 who 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 child they live with, including stepchildren

•Any spouse they live with

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

Complete Step 2 for each person in your household.

Start with yourself, then add other adults and children. If you have more than 2 people in your household, you’ll need to make a copy of the pages and attach them.

You don’t need to provide immigration status or SSNs for household 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.

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov, or call us at 1-800-318-2596. Para obtener una copia de este formulario en Español, llame 1-800-318-2596. If you need help in a language other than English, call 1-800-318-2596 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users can call 1-855-889-4325.

Complete Step 2 for yourself, your spouse/partner and dependents 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 the people in your household.

6.Social Security Number (SSN) 

We need an SSN if you want health coverage and have an SSN or can get one. We use SSNs to check income and other information to see who’s eligible for help paying for health coverage. For more information on getting an SSN, visit socialsecurity.gov, or call Social Security at 1-800-772-1213. TTY users can call 1-800-325-0778.

7.Do you plan to file a federal income tax return NEXT YEAR? You can still apply for coverage even if you don’t file a federal income tax return.

YES. If yes, answer items a through c.     NO. If no, skip to item c.

9.Do you need health coverage? Even if you have coverage, 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 3. Leave the rest of this page blank. 

12.Are you a naturalized or derived citizen? (This usually means you were born outside the U.S.) YES. If yes, complete a and b.     NO. If no, continue to question 13.

13. If you aren’t a U.S. citizen or U.S. national, do you have eligible immigration status?  YES. Enter document type and ID number. See instructions.

List the names and relationships of any children under 19 that live with you in your household:

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov, or call us at 1-800-318-2596. Para obtener una copia de este formulario en Español, llame 1-800-318-2596. If you need help in a language other than English, call 1-800-318-2596 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users can call 1-855-889-4325.