Oha 7210 PDF Details

Oha 7210 Form is an online form that you can use to apply for the Ohana Health Plan (OHP) medical insurance. The OHA 7210 form is also used to renew your Ohana Health Plan coverage. You can use the form to apply for yourself, your spouse, and your dependents. Learn more about how to use the OHA 7210 form in this blog post. Plus, get tips on how to complete the form accurately and quickly.

Below, you may find a number of specifics about oha 7210 PDF. It may be helpful to know its length, the typical time needed to complete the form, the fields you'll have to fill in, and so forth.

QuestionAnswer
Form NameOha 7210
Form Length23 pages
Fillable?No
Fillable fields0
Avg. time to fill out5 min 45 sec
Other namesoregon application health plan form, ohp 7210 application, ohp application 7210, oha plan

Form Preview Example

Application for Oregon

Health Plan Coverage

Need help with this

Get expert help at no cost from a certified insurance agent, community

application?

 

partner or customer service representative:

 

 

 

 

 

• Visit www.OregonHealthCare.gov to find agents and community

 

 

 

 

partners who can help you apply.

 

 

 

 

 

• Call OHP Customer Service at 1-800-699-9075 to get help or to request

 

 

 

 

a list of agents and community partners in your area. You can ask for

 

 

 

 

help in a different language, too.

 

 

 

 

 

 

 

 

 

Information you will

You will need the following information for everyone in your household:

need to provide on

• Social Security number for everyone who has one and is applying

this application:

 

 

• Alien Resident number for everyone who has one and is applying (you

 

 

 

 

 

 

 

may qualify even if you don’t have one)

 

 

 

 

 

• Birth dates

 

 

 

 

 

 

 

• Income and deductions (for example, from pay stubs or W-2 forms)

 

 

 

• Information about health insurance available to you through an

 

 

 

 

employer

 

 

 

 

 

 

 

 

 

 

AFTER COMPLETING YOUR APPLICATION MAIL OR FAX TO:

 

Mail:

 

 

Fax:

 

 

 

 

OHP Customer Service

 

503-378-5628

 

 

 

 

P.O. Box 14015

 

 

 

 

 

 

 

 

Salem, OR 97309-5032

 

 

 

 

 

 

 

Be sure to fill out all necessary pages and SIGN your application before sending.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OFFICIAL USE ONLY

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of request

 

Received

 

Program

Branch

 

Case no.

Worker ID

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Case name

 

 

 

Route to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Prime no.

 

 

SSN

App status

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Office use

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OHA 7210 (Rev 09/16)

How do we use

First we’ll ask some basic questions about each person. Then we’ll ask about

your information?

income, current health insurance, disabilities and Tribal ancestry.

 

We’ll keep all the information you provide private, as required by law.

 

See our privacy policy in the Application Guide for more information.

 

 

Who to include on

We need you to tell us about yourself and everyone else in your household.

this application

Your household includes the people below:

 

• You.

 

• Your legal spouse.

 

• Your children. Include children of all ages who you claim as dependents on

 

your taxes.

 

• Your live-in partner if you have a child together.

 

• Anyone else you include on your federal income tax return; even if they do

 

not live with you.

 

Important: Is someone living with you who is not on the list above? If they

 

want health coverage, they must fill out a separate application.

 

Please write clearly and provide as much information as possible about each

 

person when filling out this application.

 

If you are applying for more than four people, please make copies of

 

pages 5-6 and complete them for those people.

 

 

STEP 1 TELL US ABOUT YOURSELF You’ll be our primary contact

1. Legal name (first, middle, last and suffix)

2. Maiden or other names used (first, middle, last)

 

 

3.Social Security number (SSN) – An SSN is required for everyone who is applying for health coverage and who has one. An SSN is optional for others, but providing an SSN can speed up the application process.

SSN:

 

No: £Applied for SSN Newborn Don’t have SSN Not eligible for SSN Refuses to obtain SSN

 

4.

Birthdate (MM/DD/YYYY)

5. Sex:

6. Phone number £ Home

£ Work £ Cell

 

 

 

 

 

£ Male £ Female

(

)

 

 

 

 

 

 

 

 

 

 

7.

Do you live in Oregon? Answer yes, even if you are in Oregon to look for work or because of a job.

 

 

Only answer if you are applying for health coverage for yourself. £ Yes £ No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.

Email address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.

Home address (skip to #15 if you don’t have one)

 

 

 

10.

Apartment/Unit #

 

 

 

 

 

 

 

 

 

 

 

11.

City

 

12. County

13. State

 

14.

ZIP code

 

 

 

 

 

 

 

 

 

15.

If you don’t have a home address, please tell us where you spend the majority of your time and then give

 

 

 

us a mailing address (#16). County: ___________________________ State:______ ZIP code: ________

 

 

 

 

 

 

 

 

16.

Mailing address (only required if different from home address)

 

17.

Apartment/Unit #

 

 

 

 

 

 

 

 

 

 

 

18.

City

 

 

 

19. State

 

20.

ZIP code

 

 

 

 

 

 

 

 

 

 

 

 

NEED HELP? Call us at 1-800-699-9075/TTY 711. Monday to Friday 7 a.m. to 6 p.m.

2

OHA 7210 (Rev 09/16)

 

STEP 1 Primary Contact, continued

21.In what language do you want us to speak with you?

22.In what language do you want us to write to you?

23.Do you need written materials in an alternate format? £ Yes £ No

If yes, which? £ Braille £ Oral presentation £ Computer disk £ Audio tape £ Large print

24.Are you pregnant? £ Yes £ No

25.Is anyone else in your household pregnant? £ Yes £ No

26.Do you, the primary contact, plan to file a 2017 federal income tax return in 2018? Answer “yes” if you plan to file, even if you will not owe taxes or are getting a refund. You can apply for health coverage, even if you don’t plan to file taxes.

£ YES. If yes, complete a-b below. £ NO. If no, skip to #27.

a.What will your filing status be on your 2017 tax return?

£ Single £ Head of household £ Qualifying Widow(er) Married filing: £ Jointly £ Separately

If married, spouse’s name?___________________________________________________________

b.Do you have any tax dependents? List all dependents regardless of their age or address. £ Yes £ No

First/last name and birthdate of each dependent: ________________________________________

________________________________________________________________________________

Note: for each person listed as a dependent, complete Step 2.

27.Are you claimed as a dependent on anyone else’s tax return? £ Yes £ No

If yes, list first/last name and birthdate of the tax filer:________________________________________

How are you related to the tax filer? ______________________________________________________

28.If Hispanic/Latino ethnicity — check all that apply

£Mexican £ Mexican American £ Chicano/a £ Puerto Rican £ Cuban £ Other £ Decline to answer

29.Race — check all that apply

£American Indian or Alaska Native £ Asian Indian £ Black or African American £ Chinese

£Filipino £ Guamanian or Chamorro £ Japanese £ Korean £ Native Hawaiian £ Other Asian

£Other Pacific Islander £ Samoan £ Vietnamese £ White £ Decline to answer

30.Is your 2016 tax filing information the same as listed for 2017?

£YES. £ NO. If no, complete Appendix D - 2016 Tax Filing Status

31.Are you applying for health coverage for yourself? You can apply even if you already have health coverage.

£ YES. If yes, go to #32. £ NO. If no, skip to page 5 for Step 2.

NEED HELP? Call us at 1-800-699-9075/TTY 711. Monday to Friday 7 a.m. to 6 p.m.

3

OHA 7210 (Rev 09/16)

 

STEP 1 Primary Contact, continued

32.Are you a U.S. citizen or national? £ YES. If yes, skip to #34. £ NO

33.If you are not a U.S. citizen or national, do you have an eligible immigration status?

We only use this information to determine eligibility. See the Application Guide for more information

about eligible immigration statuses.

£YES. If yes, complete a-f. £ NO. If no, skip to #34.

a.Immigration document type: ____________________________________

b.Document ID #: _______________________________________________

c.Status: ______________________________________________________

d.Date status gained: _________________

e.Have you lived in the U.S. since 1996? £ Yes £ No

f.Are you, your spouse or a parent a veteran or an active-duty member of the U.S. military? £ Yes £ No

34.Are you the primary caretaker for any children under age 19 who: 1) live with you and 2) are related to you but are not your own children? For example, a grandparent who is the primary caretaker for a grandchild.

£ Yes £ No

If yes, list first/last name of child(ren). Do not include your adopted, biological or step children: ________

______________________________________________________________________________________

______________________________________________________________________________________

NEED HELP? Call us at 1-800-699-9075/TTY 711. Monday to Friday 7 a.m. to 6 p.m.

4

OHA 7210 (Rev 09/16)

 

 

STEP 2

ADDITIONAL HOUSEHOLD MEMBER – PERSON 2

Complete Step 2 for everyone in your household. See page 2 for more information about who to include on your application.

If you are listing more than four people in your household, please make copies of pages 5-6 and complete them for those people.

 

1.

Legal name (first, middle, last and suffix)

2. Maiden or other names used (first, middle, last)

 

 

 

 

 

 

3.

Relationship to you

 

 

 

 

 

 

4.

Social Security number (SSN) – An SSN is required for everyone who is applying for health coverage and

 

 

who has one. An SSN is optional for others, but providing an SSN can speed up the application process.

SSN:

No: £Applied for SSN Newborn Don’t have SSN Not eligible for SSN Refuses to obtain SSN

5.Birthdate (MM/DD/YYYY)

6. Sex: £ Male £ Female

7.Does Person 2 live in Oregon? Answer yes, even if you are in Oregon to look for work or because of a job. Only answer if you are applying for health coverage for Person 2. £ Yes £ No

8.Does Person 2 live at the same address as you? £ Yes £ No

a.If no, why not? (choose one) £ Alcohol/drug rehab facility £ Foster care £ Incarcerated

£Job £ Long term medical care £ Mental health facility £ Military £ Other facility £ School

£Separate residence £ Short term medical care £ No home address

b.If no, list home address: _______________________________________________________________

9.Does Person 2 plan to file a 2017 federal income tax return in 2018? Answer “yes” if Person 2 plans to file, even if they will not owe taxes or are getting a refund. Person 2 can apply for health coverage, even if they don’t plan to file taxes.

£YES. If yes, complete a-b below. £ NO. If no, skip to #10.

a.What will Person 2's filing status be on their 2017 tax return?

£ Single £ Head of household £ Qualifying Widow(er) Married filing: £ Jointly £ Separately

If married, spouse’s name?___________________________________________________________

b.Does Person 2 have any tax dependents? List all dependents regardless of their age or address. £ Yes £ No

First/last name and birthdate of each dependent: ________________________________________

________________________________________________________________________________

Note: for each person listed as a dependent, complete Step 2.

10.Is Person 2 claimed as a dependent on anyone else’s tax return? £ Yes £ No

If yes, list first/last name and birthdate of the tax filer:________________________________________

How is Person 2 related to the tax filer? ___________________________________________________

11.Is Person 2's 2016 tax filing information the same as listed for 2017?

£YES. £ NO. If no, complete Appendix D - 2016 Tax Filing Status

NEED HELP? Call us at 1-800-699-9075/TTY 711. Monday to Friday 7 a.m. to 6 p.m.

5

OHA 7210 (Rev 09/16)

 

 

STEP 2

Person 2, continued

 

 

 

12.If Hispanic/Latino ethnicity — check all that apply

£Mexican £ Mexican American £ Chicano/a £ Puerto Rican £ Cuban £ Other £ Decline to answer

13.Race — check all that apply

£American Indian or Alaska Native £ Asian Indian £ Black or African American £ Chinese

£Filipino £ Guamanian or Chamorro £ Japanese £ Korean £ Native Hawaiian £ Other Asian

£Other Pacific Islander £ Samoan £ Vietnamese £ White £ Decline to answer

14.Is Person 2 applying for health coverage? Person 2 can apply even if they already have health coverage.

£YES. If yes, go to #15.

£NO. If no, and there is someone else you need to include on this application, skip to page 7. If there is no one else you need to include on this application, skip to page 11 for Step 3.

15.Is Person 2 a U.S. citizen or national? £ YES. If yes, skip to #17. £ NO

16.If Person 2 is not a U.S. citizen or national, does Person 2 have an eligible immigration status?

We only use this information to determine eligibility. See the Application Guide for more information

about eligible immigration statuses.

£YES. If yes, complete a-f. £ NO. If no, skip to #17.

a.Immigration document type: ____________________________________

b.Document ID #: _______________________________________________

c.Status: ______________________________________________________

d.Date status gained: _________________

e.Has Person 2 lived in the U.S. since 1996? £ Yes £ No

f.Is Person 2, their spouse or a parent a veteran or an active-duty member of the U.S. military? £ Yes £ No

17.Is Person 2 the primary caretaker for any children under age 19 who: 1) live with Person 2 and 2) are related to Person 2 but are not Person 2's own children? For example, a grandparent who is the primary caretaker for a grandchild.

£ Yes £ No

If yes, list first/last name of child(ren). Do not include Person 2's adopted, biological or step children:

______________________________________________________________________________________

______________________________________________________________________________________

NEED HELP? Call us at 1-800-699-9075/TTY 711. Monday to Friday 7 a.m. to 6 p.m.

6

OHA 7210 (Rev 09/16)

 

 

 

 

STEP 2

ADDITIONAL HOUSEHOLD MEMBER – PERSON 3

 

1.

Legal name (first, middle, last and suffix)

 

2. Maiden or other names used (first, middle, last)

 

 

 

 

 

 

 

 

 

3.

Relationship to you

 

 

 

 

 

 

 

 

 

 

 

4.

Social Security number (SSN) – An SSN is required for everyone who is applying for health coverage and

 

 

 

who has one. An SSN is optional for others, but providing an SSN can speed up the application process.

SSN:

 

No: £Applied for SSN

Newborn Don’t have SSN Not eligible for SSN Refuses to obtain SSN

5.Birthdate (MM/DD/YYYY)

6. Sex: £ Male £ Female

7.Does Person 3 live in Oregon? Answer yes, even if you are in Oregon to look for work or because of a job.

Only answer if you are applying for health coverage for Person 3. £ Yes £ No

8.Does Person 3 live at the same address as you? £ Yes £ No

a.If no, why not? (choose one) £ Alcohol/drug rehab facility £ Foster care £ Incarcerated

£Job £ Long term medical care £ Mental health facility £ Military £ Other facility £ School

£Separate residence £ Short term medical care £ No home address

b.If no, list home address: _______________________________________________________________

9.Does Person 3 plan to file a 2017 federal income tax return in 2018? Answer “yes” if Person 3 plans to file, even if they will not owe taxes or are getting a refund. Person 3 can apply for health coverage, even if they don’t plan to file taxes.

£YES. If yes, complete a-b below. £ NO. If no, skip to #10.

a.What will Person 3's filing status be on their 2017 tax return?

£ Single £ Head of household £ Qualifying Widow(er) Married filing: £ Jointly £ Separately

If married, spouse’s name?___________________________________________________________

b.Does Person 3 have any tax dependents? List all dependents regardless of their age or address. £ Yes £ No

First/last name and birthdate of each dependent: ________________________________________

________________________________________________________________________________

Note: for each person listed as a dependent, complete Step 2.

10.Is Person 3 claimed as a dependent on anyone else’s tax return? £ Yes £ No

If yes, list first/last name and birthdate of the tax filer:________________________________________

How is Person 3 related to the tax filer? ___________________________________________________

11.If Hispanic/Latino ethnicity — check all that apply

£Mexican £ Mexican American £ Chicano/a £ Puerto Rican £ Cuban £ Other £ Decline to answer

12.Race — check all that apply

£American Indian or Alaska Native £ Asian Indian £ Black or African American £ Chinese

£Filipino £ Guamanian or Chamorro £ Japanese £ Korean £ Native Hawaiian £ Other Asian

£Other Pacific Islander £ Samoan £ Vietnamese £ White £ Decline to answer

NEED HELP? Call us at 1-800-699-9075/TTY 711. Monday to Friday 7 a.m. to 6 p.m.

7

OHA 7210 (Rev 09/16)

 

 

STEP 2

Person 3, continued

 

 

 

13.Is Person 3 applying for health coverage? Person 3 can apply even if they already have health coverage.

£YES. If yes, go to #14.

£NO. If no, and there is someone else you need to include on this application, skip to page 9. If there is no one else you need to include on this application, skip to page 11 for Step 3.

14.Is Person 3 a U.S. citizen or national? £ YES. If yes, skip to #16. £ NO

15.If Person 3 is not a U.S. citizen or national, does Person 3 have an eligible immigration status?

We only use this information to determine eligibility. See the Application Guide for more information about eligible immigration statuses.

£YES. If yes, complete a-f. £ NO. If no, skip to #16.

a. Immigration document type: ____________________________________

b. Document ID #: _______________________________________________

c.Status: ______________________________________________________

d.Date status gained: _________________

e.Has Person 3 lived in the U.S. since 1996? £ Yes £ No

f.Is Person 3, their spouse or a parent a veteran or an active-duty member of the U.S. military? £ Yes £ No

16.Is Person 3 the primary caretaker for any children under age 19 who: 1) live with Person 3 and 2) are related to Person 3 but are not Person 3's own children? For example, a grandparent who is the primary

caretaker for a grandchild.

£Yes £ No

If yes, list first/last name of child(ren). Do not include Person 3's adopted, biological or step children:

______________________________________________________________________________________

______________________________________________________________________________________

17.Is Person 3's 2016 tax filing information the same as listed for 2017?

£YES. £ NO. If no, complete Appendix D - 2016 Tax Filing Status

NEED HELP? Call us at 1-800-699-9075/TTY 711. Monday to Friday 7 a.m. to 6 p.m.

8

OHA 7210 (Rev 09/16)

 

 

 

 

STEP 2

ADDITIONAL HOUSEHOLD MEMBER – PERSON 4

 

1.

Legal name (first, middle, last and suffix)

 

2. Maiden or other names used (first, middle, last)

 

 

 

 

 

 

 

 

 

3.

Relationship to you

 

 

 

 

 

 

 

 

 

 

 

4.

Social Security number (SSN) – An SSN is required for everyone who is applying for health coverage and

 

 

 

who has one. An SSN is optional for others, but providing an SSN can speed up the application process.

SSN:

 

No: £Applied for SSN

Newborn Don’t have SSN Not eligible for SSN Refuses to obtain SSN

5.Birthdate (MM/DD/YYYY)

6. Sex: £ Male £ Female

7.Does Person 4 live in Oregon? Answer yes, even if you are in Oregon to look for work or because of a job.

Only answer if you are applying for health coverage for Person 4. £ Yes £ No

8.Does Person 4 live at the same address as you? £ Yes £ No

a.If no, why not? (choose one) £ Alcohol/drug rehab facility £ Foster care £ Incarcerated

£Job £ Long term medical care £ Mental health facility £ Military £ Other facility £ School

£Separate residence £ Short term medical care £ No home address

b.If no, list home address: _______________________________________________________________

9.Does Person 4 plan to file a 2017 federal income tax return in 2018? Answer “yes” if Person 4 plans to file, even if they will not owe taxes or are getting a refund. Person 4 can apply for health coverage, even if they don’t plan to file taxes.

£YES. If yes, complete a-b below. £ NO. If no, skip to #10.

a.What will Person 4's filing status be on their 2017 tax return?

£ Single £ Head of household £ Qualifying Widow(er) Married filing: £ Jointly £ Separately

If married, spouse’s name?___________________________________________________________

b.Does Person 4 have any tax dependents? List all dependents regardless of their age or address. £ Yes £ No

First/last name and birthdate of each dependent: ________________________________________

________________________________________________________________________________

Note: for each person listed as a dependent, complete Step 2.

10.Is Person 4 claimed as a dependent on anyone else’s tax return? £ Yes £ No

If yes, list first/last name and birthdate of the tax filer:________________________________________

How is Person 4 related to the tax filer? ___________________________________________________

11.If Hispanic/Latino ethnicity — check all that apply

£Mexican £ Mexican American £ Chicano/a £ Puerto Rican £ Cuban £ Other £ Decline to answer

12.Race — check all that apply

£American Indian or Alaska Native £ Asian Indian £ Black or African American £ Chinese

£Filipino £ Guamanian or Chamorro £ Japanese £ Korean £ Native Hawaiian £ Other Asian

£Other Pacific Islander £ Samoan £ Vietnamese £ White £ Decline to answer

NEED HELP? Call us at 1-800-699-9075/TTY 711. Monday to Friday 7 a.m. to 6 p.m.

9

OHA 7210 (Rev 09/16)

 

 

STEP 2

Person 4, continued

 

 

 

13.Is Person 4 applying for health coverage? Person 4 can apply even if they already have health coverage.

£YES. If yes, go to #14.

£NO. If no, skip to page 11 for Step 3.

14.Is Person 4 a U.S. citizen or national? £ YES. If yes, skip to #16. £ NO

15.If Person 4 is not a U.S. citizen or national, does Person 4 have an eligible immigration status?

We only use this information to determine eligibility. See the Application Guide for more information about eligible immigration statuses.

£YES. If yes, complete a-f. £ NO. If no, skip to #16.

a. Immigration document type: ____________________________________

b. Document ID #: _______________________________________________

c.Status: ______________________________________________________

d.Date status gained: _________________

e.Has Person 4 lived in the U.S. since 1996? £ Yes £ No

f.Is Person 4, their spouse or a parent a veteran or an active-duty member of the U.S. military? £ Yes £ No

16.Is Person 4 the primary caretaker for any children under age 19 who: 1) live with Person 4 and 2) are related to Person 4 but are not Person 4's own children? For example, a grandparent who is the primary

caretaker for a grandchild.

£Yes £ No

If yes, list first/last name of child(ren). Do not include Person 4's adopted, biological or step children:

______________________________________________________________________________________

______________________________________________________________________________________

17.Is Person 4's 2016 tax filing information the same as listed for 2017?

£YES. £ NO. If no, complete Appendix D - 2016 Tax Filing Status

NEED HELP? Call us at 1-800-699-9075/TTY 711. Monday to Friday 7 a.m. to 6 p.m.

10

OHA 7210 (Rev 09/16)

 

Watch Oha 7210 Video Instruction

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .