Njfamilycare Application PDF Details

The NJFamilyCare application form stands as a pivotal gateway for individuals and families in New Jersey seeking health coverage and financial assistance for their medical costs. This comprehensive form is designed to determine eligibility for free or low-cost insurance through Medicaid or the Children’s Health Insurance Program (CHIP), known collectively as NJ FamilyCare. In addition to offering a potential new tax credit that could assist with premium payments, the application caters to a wide demographic. It ushers in an opportunity for individuals, regardless of their current health insurance status, to explore potentially more affordable or comprehensive coverage options. Emphasizing inclusivity, the form welcomes families that include immigrants, ensuring that immigration status will not be a barrier to applying. Required information includes Social Security numbers (or document numbers for legal immigrants needing insurance), employer and income details for family members, current health insurance policy numbers, and information on any job-related health insurance available. The aim is to streamline the application process, ensuring that income and other pertinent information are collected to accurately gauge eligibility for assistance with health coverage costs, while maintaining the privacy and security of the provided information. Additionally, it outlines the follow-up procedure post-application submission, promising a review and response within 1–2 weeks, and provides resources for assistance with the application process, including online support, a help center phone line, in-person counseling, and assistance in languages other than English to accommodate a diverse applicant pool.

QuestionAnswer
Form NameNjfamilycare Application
Form Length16 pages
Fillable?No
Fillable fields0
Avg. time to fill out4 min
Other namesnjfamilycare org log in, nj familycare, nj familycare renewal application 2020 pdf, nj familycare application

Form Preview Example

Application for Health Coverage & Help Paying Costs

Use this application to see what coverage choices you qualify for

Free or low-cost insurance from Medicaid or the Children’s Health Insurance Program (CHIP), known as NJ FamilyCare

you stay well

A new tax credit that can help pay your premiums for health coverage

Who can use this

• Use this application to apply for anyone in your family.

application?

• Apply even if you or your child already has health coverage. You could be

eligible for lower-cost or free coverage.

 

 

• If you’re single, you may be able to use a short form.

 

Visit njfamilycare.org.

 

• Families that include immigrants can apply. You can apply for your

 

 

 

 

immigration status or chances of becoming a permanent resident or

 

 

 

 

citizen.

 

 

 

d to

 

 

 

 

complete Appendix C.

TO KNOW

 

Apply faster

Apply faster online at njfamilycare.org.

 

online

 

 

 

What you may

• Social Security Numbers (or document numbers for any legal immigrants

 

THINGS

 

 

who need insurance)

 

need to apply

 

 

• Employer and income information for everyone in your family (for

 

 

 

 

 

 

 

 

 

example, from paystubs, W-2 forms, or wage and tax statements)

 

 

 

• Policy numbers for any current health insurance

 

 

 

• Information about any job-related health insurance available to your family

 

 

Why do we ask for

We ask about income and other information to let you know what coverage

 

 

this information?

you qualify for and if you can get any help paying for it. We’ll keep all the

 

 

information you provide private and secure, as required by law. To view

 

 

 

 

 

 

the Privacy Act Statement, go to njfamilycare.org.

 

 

What happens next?

Send your complete, signed application to the address on page 7.

 

 

 

If you don’t have all the information we ask for, sign and submit

 

 

 

your application anyway. We’ll follow-up with you within 1–2 weeks. You’ll

 

 

 

get instructions on the next steps to complete your health coverage. If you

 

 

 

don’t hear from us, visit njfamilycare.org or call 1-800-701-0710. Filling out

 

 

 

this application doesn’t mean you have to buy health coverage.

 

 

Get help with this

Online: njfamilycare.org

 

 

application

Phone: Call our Help Center at 1-800-701-0710.

 

 

 

 

In person: There may be counselors in your area who can help. Visit our website or call 1-800-701-0710 for more information.

En Español: Llame a nuestro centro de ayuda gratis al

1-800-701-0710.

NJ FamilyCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, sex, age or

E-0919

disability. If you speak any other language, language assistance services are available at no cost to you. Call 1-800-701-0710 (TTY: 1-800-701-0720).

-

NJFC-APP

 

STEP 1 Tell us about yourself.

(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.

Current 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.

What is your preferred spoken or written language (if not English)?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STEP 2 Tell us about your family.

Family Planning (Plan First Program)

If any person on this application is not eligible for NJ FamilyCare, would you like them to be evaluated for family planning services (Plan First Program)?

Yes

Check here for all applicants on this application to be evaluated for family planning services.

Plan First is a program for women and men that provides only family planning and related services (such as birth control and reproductive health care). Family planning services do not provide minimum essential health care coverage (such as routine care).

Who do you need to include on this application?

DO Include:

Yourself

Your spouse

Your children under 21 who live with you

Your unmarried partner who needs health coverage

Anyone you include on your tax return, even if they don’t live with you

Anyone else under 21 who you take care of and lives with you

You DON’T have to include:

Your unmarried partner who doesn’t need health coverage

Your unmarried partner’s children

(if you’re over 21)

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.

NJ FamilyCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, sex, age or disability. If you speak any other language, language assistance services are available at no cost to you. Call 1-800-701-0710 (TTY: 1-800-701-0720).

Page 1 of 7

NJFC-APP-E-0919

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

with you.

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

2. Relationship to you?

SELF

3.Date of birth (mm/dd/yyyy)

5.Sex Male Female

4. Citizenship Status:

US Citizen

Refugee

Asylee

Not Lawfully Admitted

Legal Alien ____________ USCIS/Alien #__________________________

Immigration Card #__________________________

Date of Entry

 

 

 

 

Official Name on Immigration Document/Card (AKA) ____________________________________________________________

6. 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 1-800-772-1213 or visit socialsecurity.gov. TTY users should call 1-800-325-0778.

7a. Check this box if 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.)

Will you file jointly with your spouse?

Yes No

If yes, name of spouse:

Will you claim any dependents on your tax return? If yes, list name(s) of dependents:

Yes No

7b. Check this box if you will be claimed as a dependent on someone’s federal tax return.

If yes, please list the name of the tax filer:

How are you related to the tax filer?

8. Are you pregnant? Yes

No a.If yes, how many babies are expected during this pregnancy? _________ Due Date _______________

9.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 3. Leave the rest of this page blank.

10. 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

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

Yes

No

12. Do you live with at least one child under the age of 19, and are you the main person taking care of this child?

Yes

No

13. Are you a full-time student?

Yes

No

14. Were you in foster care at age 18 or older?

Yes

No

15.If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.)

Mexican

Mexican American

Chicano/a

Puerto Rican

Cuban

Other

16.Race (OPTIONAL—check all that apply.)

White

Black or African American

Native American Indian or Alaska Native Asian Indian

Chinese

Filipino Japanese

Korean

Vietnamese

Other Asian

Native Hawaiian

Guamanian or Chamorro Samoan

Other

NJ FamilyCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, sex, age or disability. If you speak any other language, language assistance services are available at no cost to you. Call 1-800-701-0710 (TTY: 1-800-701-0720).

Page 2 of 7

NJFC-APP-E-0919

 

STEP 2: PERSON 1

(Continue with yourself)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Job & Income Information

 

 

 

 

 

 

 

 

 

 

Employed

 

 

Not employed

 

Self-employed

 

 

 

If you’re currently employed, tell us

 

Skip to question 27.

Skip to question 26.

 

about your income. Start with question

 

 

 

 

 

 

 

 

 

 

17.

 

 

 

 

 

 

 

 

 

 

 

 

 

CURRENT JOB 1:

 

 

 

 

 

 

 

 

 

 

 

 

17. Employer name and address

 

 

 

 

 

 

18. Employer phone number

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19. Wages/tips (before taxes)

Hourly

Weekly

Every 2 weeks

Twice a month

Monthly

Yearly

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20. Average hours worked each WEEK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CURRENT JOB 2: (If you have more jobs and need more space, attach another sheet of paper.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21. Employer name and address

 

 

 

 

 

 

22. Employer phone number

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

23. Wages/tips (before taxes)

Hourly

Weekly

Every 2 weeks

Twice a month

Monthly

Yearly

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

24. Average hours worked each WEEK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

25. In the past year, did you:

Change jobs Stop working

Start working fewer hours

None of these

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

26.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?

 

$

 

 

27.OTHER INCOME THIS MONTH: Check all that apply, and give the amount and how often you get it. NOTE: You don’t need to tell us about child support, veteran’s payment, or Supplemental Security Income (SSI).

None

 

 

 

 

Net farming/fishing

 

 

 

 

Unemployment

$

 

How often?

 

$

 

 

How often?

 

 

Net rental/royalty

$

 

 

How often?

Pensions

$

 

How often?

 

 

 

 

 

Other income

$

 

 

How often?

 

 

 

 

Social Security

$

 

How often?

 

 

 

 

 

Type:

 

 

 

 

 

Retirement accounts

$

 

How often?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Alimony received

$

 

How often?

 

 

 

 

 

 

 

28. DEDUCTIONS: Check all that apply, and give the amount and how often you get it.

If you pay for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower.

NOTE: You shouldn’t include a cost that you already considered in your answer to net self-employment (question 27b).

Alimony paid

$

 

 

How often?

 

 

 

Other deductions

$

 

 

How often?

Student loan interest

$

 

 

How often?

 

 

 

Type:

 

 

 

 

 

29.YEARLY INCOME: Complete only if your income changes from month to month.

If you don’t expect changes to your monthly income, skip to the next person.

Your total income this year

Your total income next

$

$

 

 

THANKS! This is all we need to know about you.

NJ FamilyCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, sex, age or disability. If you speak any other language, language assistance services are available at no cost to you. Call 1-800-701-0710 (TTY: 1-800-701-0720).

Page 3 of 7

NJFC-APP-E-0919

Guamanian or Chamorro Samoan
Other

STEP 2: PERSON 2

If you have more than two people to include, make a

 

 

 

 

 

 

 

 

 

copy of Step 2: Person 2 (pages 4 and 5) and complete.

 

 

 

 

 

 

 

 

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

with you.

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

2. Relationship to you?

3. Date of birth (mm/dd/yyyy)

5. Sex

Male

Female

4. Citizenship Status:

US Citizen

Refugee

Asylee

Not Lawfully Admitted

Legal Alien ____________ USCIS/Alien #__________________________

Immigration Card #__________________________

Date of Entry

 

 

 

 

Official Name on Immigration Document/Card (AKA) ____________________________________________________________

6.

Social Security number (SSN)

 

 

 

 

 

-

 

 

 

-

 

 

 

 

 

 

 

We need this if you want health coverage and have an SSN.

 

 

 

 

 

 

 

 

 

7.

Does PERSON 2 live at the same address as you?

Yes

 

 

No

 

If no, list address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8a. Check this box if PERSON 2 plans 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.)

Will PERSON 2 file jointly with their spouse?

If yes, name of spouse:

Yes No

8b.

Will PERSON 2 claim any dependents on their tax return? Yes No

If yes, list name(s) of dependents:

Check this box if PERSON 2 plans to be claimed as a dependent on someone’s federal tax return. If yes, please list the name of the tax filer:

How is PERSON 2 related to the tax filer?

9. Is PERSON 2 pregnant?

Yes

No a. If yes, how many babies are expected during this pregnancy? _________ Due Date _______________

10.Does PERSON 2 need health coverage?

(Even if they 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 5.

 

Leave the rest of this page blank.

 

 

11.Does PERSON 2 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

12. Does PERSON 2 want help paying for

13. Does PERSON 2 live with at least one child under

 

14. Was PERSON 2 in foster care at age

 

medical bills from the last 3 months?

the age of 19, and are they the main person

 

18 or older?

Yes

No

taking care of this child?

Yes

No

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

Please answer the following questions if PERSON 2 is 22 or younger:

15. Did PERSON 2 have insurance through a job and lose it within the past 3 months?

Yes

No

 

a. If yes, end date:

 

b. Reason the insurance ended:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16.Is PERSON 2 a full-time student? Yes No

17.If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.)

Mexican

Mexican American

Chicano/a

Puerto Rican

Cuban

Other

18.Race (OPTIONAL—check all that apply.)

White

Black or African American

Native American Indian or Alaska Native Asian Indian

Chinese

Filipino

Japanese

Korean

Vietnamese

Other Asian

Native Hawaiian

Now, tell us about any income from PERSON 2

NJ FamilyCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, sex, age or disability. If you speak any other language, language assistance services are available at no cost to you. Call 1-800-701-0710 (TTY: 1-800-701-0720).

Page 4 of 7

NJFC-APP-E-0919

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Feel free to type in the next information to complete the nj family care application nj PDF:

portion of empty spaces in nj familycare renewal application 2020 printable

Enter the appropriate information in the area STEP, Tell us about yourself, We need one adult in the family to, First name Middle name Last name, Home address Leave blank if you, Apartment or suite number, City, State, ZIP code, County, Current mailing address if, Apartment or suite number, City, State, and ZIP code.

nj familycare renewal application 2020 printable STEP, Tell us about yourself, We need one adult in the family to, First name Middle name Last name, Home address Leave blank if you, Apartment or suite number, City, State, ZIP code, County, Current mailing address if, Apartment or suite number, City, State, and ZIP code blanks to fill

Describe the most important details the What is your preferred spoken or, STEP, Tell us about your family, Family Planning Plan First Program, If any person on this application, Yes Check here for all applicants, Plan First is a program for women, Who do you need to include on this, DO Include Yourself cid Your, You DONT have to include cid cid, Your unmarried partner who doesnt, if youre over, and cid segment.

nj familycare renewal application 2020 printable What is your preferred spoken or, STEP, Tell us about your family, Family Planning Plan First Program, If any person on this application, Yes Check here for all applicants, Plan First is a program for women, Who do you need to include on this, DO Include Yourself cid Your, You DONT have to include cid cid, Your unmarried partner who doesnt, if youre over, and cid fields to fill out

Take the time to place the rights and obligations of the sides inside the with you, First name Middle name Last name, Relationship to you, SELF, Date of birth mmddyyyy, Sex, Male, Female, dettimdA yllufwaL toN eelysA, Social Security number SSN, We need this if you want health, Check this box if you plan to file, Will you file jointly with your, Yes No, and If yes name of spouse box.

nj familycare renewal application 2020 printable with you, First name Middle name Last name, Relationship to you, SELF, Date of birth mmddyyyy, Sex, Male, Female, dettimdA yllufwaL toN eelysA, Social Security number SSN, We need this if you want health, Check this box if you plan to file, Will you file jointly with your, Yes No, and If yes name of spouse blanks to fill out

Fill in the form by looking at all of these areas: Are you pregnant, Yes, No a, If yes, how many babies are expected durin, g this pregnancy, Due Date, Do you need health coverage, Even if you have insurance there, YES If yes answer all the, NO If no SKIP to the income, Do you have a physical mental or, chores etc or live in a medical, Yes, and Do you want help paying for.

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