Oregon Health Plan Application Online 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

USE THROUGH NOVEMBER 2015

Need help with this

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

applicaion?

partner or customer service representaive:

 

• Visit www.OregonHealthCare.gov to ind 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 diferent language, too.

 

 

Informaion you will

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

need to provide on

Social Security number for everyone who has one and is applying

this applicaion:

• 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 deducions (for example, from pay stubs or W-2 forms)

 

Informaion about health insurance available to you through an

 

 

employer

AFTER COMPLETING YOUR APPLICATION MAIL OR FAX TO:

Mail:

Fax:

OHP Customer Service

503-373-7493

P.O. Box 14520

 

Salem, OR 97309-5044

 

Be sure to ill out all necessary pages and SIGN your applicaion before sending.

 

 

OFFICIAL USE ONLY

 

 

 

 

 

 

 

 

 

 

Date of request

Received

 

Program

Branch

Case no.

Worker ID

 

 

 

 

 

 

 

 

 

 

Case name

 

 

Route to

 

 

 

 

 

 

 

 

 

 

Prime no.

 

SSN

App status

 

 

 

 

 

 

 

 

 

 

Oice use

 

 

 

 

 

 

 

 

 

 

OHA 7210 (Rev 06/15)

How do we use First we’ll ask some basic quesions about each person. Then we’ll ask about your informaion? income, current health insurance, disabiliies and Tribal ancestry.

We’ll keep all the informaion you provide private, as required by law. See our privacy policy in the Applicaion Guide for more informaion.

Who to include on We’ll need you to tell us about yourself and everyone else in your

this applicaion household. Your household includes the people below if they are living with you:

You

Your legal spouse

Your children. Include children you claim as a dependent on your taxes (regardless of their age).

Your live-in partner (only if you have a child together)

Also include anyone else you include on your federal income tax return, even if they do not live with you.

Important: Anyone living with you who is not included in the list above and wants health coverage must ill out a separate applicaion.

Please write clearly and provide as much informaion as possible about each person when illing out this applicaion.

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 (irst, middle, last and suix)

2. Maiden or other names used (irst, 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 opional for others, but providing an SSN can speed up the applicaion process.

£Don’t have an SSN £ Have applied for an 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 ime and then give

 

 

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

 

 

 

 

16.

Mailing address (only required if diferent from home address)

 

17.

Apartment/Unit #

 

 

 

 

 

 

 

 

 

18.

City

 

 

 

19. State

 

20.

ZIP code

 

 

 

 

 

 

 

 

 

 

2

NEED HELP? Call us at 1-800-699-9075/TTY 711. Monday to Friday 7 a.m. to 6 p.m. OHA 7210 (Rev 06/15)

STEP 1 Primary Contact, coninued

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 writen materials in an alternate format? £ Yes £ No

If yes, which? £ Braille £ Oral presentaion £ 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 ile a 2015 federal income tax return in 2016? Answer “yes” if you plan to ile, even if you will not owe taxes or are geing a refund. You can apply for health coverage, even if you don’t plan to ile taxes.

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

a.What will your iling status be on your 2015 tax return?

£ Single £ Head of household £ Qualifying Widow(er) Married iling: £ 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 irst/last name and birthdate of the tax iler:________________________________________

How are you related to the tax iler? ______________________________________________________

28.If Hispanic/Laino 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 Naive £ Asian Indian £ Black or African American £ Chinese

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

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

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

£ YES. If yes, go to #31. £ 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. OHA 7210 (Rev 06/15)

3

STEP 1 Primary Contact, coninued

31.Are you a U.S. ciizen or naional? £ YES. If yes, skip to #33. £ NO

32.If you are not a U.S. ciizen or naional, do you have an eligible immigraion status?

We only use this informaion to determine eligibility. See the Applicaion Guide for more informaion about eligible immigraion statuses.

£ YES. If yes, complete a-f. £ NO. If no, skip to #33.

a. Immigraion 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 acive-duty member of the U.S. military? £ Yes £ No

33.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 irst/last name of child(ren). Do not include your adopted, biological or step children: ________

______________________________________________________________________________________

______________________________________________________________________________________

4

NEED HELP? Call us at 1-800-699-9075/TTY 711. Monday to Friday 7 a.m. to 6 p.m. OHA 7210 (Rev 06/15)

 

STEP 2

ADDITIONAL HOUSEHOLD MEMBER – PERSON 2

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

If you are lising more than four people in your household, please make copies of pages 5-6 and complete

them for those people.

1. Legal name (irst, middle, last and suix)

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

3.Relaionship 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 opional for others, but providing an SSN can speed up the applicaion process.

£Don’t have an SSN £ Have applied for an 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 ile a 2015 federal income tax return in 2016? Answer “yes” if Person 2 plans to ile, even if they will not owe taxes or are geing a refund. Person 2 can apply for health coverage, even if they don’t plan to ile taxes.

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

a.What will Person 2's iling status be on their 2015 tax return?

£ Single £ Head of household £ Qualifying Widow(er) Married iling: £ 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 irst/last name and birthdate of the tax iler:________________________________________

How is Person 2 related to the tax iler? ___________________________________________________

NEED HELP? Call us at 1-800-699-9075/TTY 711. Monday to Friday 7 a.m. to 6 p.m. OHA 7210 (Rev 06/15)

5

 

STEP 2

Person 2, coninued

 

 

 

11.If Hispanic/Laino 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 Naive £ Asian Indian £ Black or African American £ Chinese

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

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

13.Is Person 2 applying for health coverage? Person 2 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 applicaion, skip to page 7. If there is no one else you need to include on this applicaion, skip to page 11 for Step 3.

14.Is Person 2 a U.S. ciizen or naional? £ YES. If yes, skip to #16. £ NO

15.If Person 2 is not a U.S. ciizen or naional, does Person 2 have an eligible immigraion status?

We only use this informaion to determine eligibility. See the Applicaion Guide for more informaion about eligible immigraion statuses.

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

a. Immigraion 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 acive-duty member of the U.S. military? £ Yes £ No

16.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 irst/last name of child(ren). Do not include Person 2's adopted, biological or step children:

______________________________________________________________________________________

______________________________________________________________________________________

6

NEED HELP? Call us at 1-800-699-9075/TTY 711. Monday to Friday 7 a.m. to 6 p.m. OHA 7210 (Rev 06/15)

STEP 2

ADDITIONAL HOUSEHOLD MEMBER – PERSON 3

1. Legal name (irst, middle, last and suix)

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

3.Relaionship 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 opional for others, but providing an SSN can speed up the applicaion process.

£Don’t have an SSN £ Have applied for an 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 ile a 2015 federal income tax return in 2016? Answer “yes” if Person 3 plans to ile, even if they will not owe taxes or are geing a refund. Person 3 can apply for health coverage, even if they don’t plan to ile taxes.

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

a.What will Person 3's iling status be on their 2015 tax return?

£ Single £ Head of household £ Qualifying Widow(er) Married iling: £ 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 irst/last name and birthdate of the tax iler:________________________________________

How is Person 3 related to the tax iler? ___________________________________________________

11.If Hispanic/Laino 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 Naive £ Asian Indian £ Black or African American £ Chinese

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

£Other Paciic 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. OHA 7210 (Rev 06/15)

7

 

STEP 2

Person 3, coninued

 

 

 

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 applicaion, skip to page 9. If there is no one else you need to include on this applicaion, skip to page 11 for Step 3.

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

15.If Person 3 is not a U.S. ciizen or naional, does Person 3 have an eligible immigraion status?

We only use this informaion to determine eligibility. See the Applicaion Guide for more informaion about eligible immigraion statuses.

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

a. Immigraion 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 acive-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 irst/last name of child(ren). Do not include Person 3's adopted, biological or step children:

______________________________________________________________________________________

______________________________________________________________________________________

8

NEED HELP? Call us at 1-800-699-9075/TTY 711. Monday to Friday 7 a.m. to 6 p.m. OHA 7210 (Rev 06/15)

STEP 2

ADDITIONAL HOUSEHOLD MEMBER – PERSON 4

1. Legal name (irst, middle, last and suix)

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

3.Relaionship 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 opional for others, but providing an SSN can speed up the applicaion process.

£Don’t have an SSN £ Have applied for an 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 ile a 2015 federal income tax return in 2016? Answer “yes” if Person 4 plans to ile, even if they will not owe taxes or are geing a refund. Person 4 can apply for health coverage, even if they don’t plan to ile taxes.

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

a.What will Person 4's iling status be on their 2015 tax return?

£ Single £ Head of household £ Qualifying Widow(er) Married iling: £ 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 irst/last name and birthdate of the tax iler:________________________________________

How is Person 4 related to the tax iler? ___________________________________________________

11.If Hispanic/Laino 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 Naive £ Asian Indian £ Black or African American £ Chinese

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

£Other Paciic 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. OHA 7210 (Rev 06/15)

9

 

STEP 2

Person 4, coninued

 

 

 

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. ciizen or naional? £ YES. If yes, skip to #16. £ NO

15.If Person 4 is not a U.S. ciizen or naional, does Person 4 have an eligible immigraion status?

We only use this informaion to determine eligibility. See the Applicaion Guide for more informaion about eligible immigraion statuses.

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

a. Immigraion 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 acive-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 irst/last name of child(ren). Do not include Person 4's adopted, biological or step children:

______________________________________________________________________________________

______________________________________________________________________________________

10

NEED HELP? Call us at 1-800-699-9075/TTY 711. Monday to Friday 7 a.m. to 6 p.m. OHA 7210 (Rev 06/15)

STEP 3

 

INCOME AND DEDUCTIONS

 

 

 

 

Does anyone listed on your applicaion have income and/or deducions?

£Yes. If yes, complete Step 3 for each person. £ No. If no, skip to page 15 for Step 4.

1. Who has income and/or deducions?

First/last name ______________________________________ Birthdate (MM/DD/YYYY)____________

2.INCOME FROM JOB(S): If employed by someone else: Tell us how much this person makes in

wages/ips (before taxes) at each job. Atach another sheet of paper if this person has more than ive jobs. If self-employed: Check the box below and then tell us how much net proit (income ater all business costs have been deducted) this person makes. Write N/A if no one gets income from a job.

This

Next

Esimated total

month

month

income this year

JOB 1 Business name and address (include city and state)

Job start date (MM/YYYY): ______________

 

 

£ Self-employed? Type of work: _______________________ $

$

$

JOB 2 Business name and address (include city and state)

 

 

Job start date (MM/YYYY): ______________

 

 

£ Self-employed? Type of work: _______________________ $

$

$

JOB 3 Business name and address (include city and state)

 

 

Job start date (MM/YYYY): ______________

 

 

£ Self-employed? Type of work: _______________________ $

$

$

JOB 4 Business name and address (include city and state)

 

 

Job start date (MM/YYYY): ______________

 

 

£ Self-employed? Type of work: _______________________ $

$

$

JOB 5 Business name and address (include city and state)

 

 

Job start date (MM/YYYY): ______________

 

 

£ Self-employed? Type of work: _______________________ $

$

$

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

OHA 7210 (Rev 06/15)

11

STEP 3

 

INCOME AND DEDUCTIONS, coninued

 

 

 

 

3.OTHER INCOME: Some people receive income from other sources. Tell us if this person receives income from any of the sources listed below. Don’t include child support, veteran’s payments or Supplemental Security Income (SSI) because they are not taxable. Write N/A if no one gets other income.

 

This

Next

Esimated total

 

month

month

income this year

Unemployment. Name of state or employer paying: _____________

$

$

$

 

 

 

 

Reirement/pension

$

$

$

 

 

 

 

Capital gains

$

$

$

 

 

 

 

Investments

$

$

$

 

 

 

 

Net rental/royalty

$

$

$

 

 

 

 

Net farming/ishing

$

$

$

 

 

 

 

Prizes/awards/gambling

$

$

$

 

 

 

 

Alimony received

$

$

$

 

 

 

 

Per capita payments from casinos

$

$

$

 

 

 

 

Taxable Tribal income

$

$

$

 

 

 

 

Other taxable income

$

$

$

 

 

 

 

Social Security/SSDI (include both taxable and non-taxable amounts)

$

$

$

 

 

 

 

4.DEDUCTIONS: Some people can deduct certain things they pay for on their federal income tax return. Tell us about the following deducions this person claims on his/her taxes. Don’t include costs that were already deducted from self-employment income on the previous page. Write N/A if no one had deducions.

Alimony paid

Student loan interest

Educator expenses

IRA contribuions

Tuiion/fees

Other deducions

This

Next

Esimated total

month

month

deducions this year

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

 

 

 

12

IMPORTANT!

If you write down income/deducion informaion, make sure you write amounts for This month, Next month and Esimated total income this year, even if it is 0. If you leave an area blank, we may have to ask you for more informaion.

NEED HELP? Call us at 1-800-699-9075/TTY 711. Monday to Friday 7 a.m. to 6 p.m. OHA 7210 (Rev 06/15)

STEP 3

 

INCOME AND DEDUCTIONS, coninued

 

 

 

 

If more than two people listed on your applicaion have income or deducions, make a copy of the front and back of this page before illing it out and include it with your applicaion.

1.Who has income and/or deducions?

First/last name ______________________________________ Birthdate (MM/DD/YYYY)____________

2.INCOME FROM JOB(S): If employed by someone else: Tell us how much this person makes in wages/ips (before taxes) at each job. Atach another sheet of paper if this person has more than ive jobs.

If self-employed: Check the box below and then tell us how much net proit (income ater all business costs have been deducted) this person makes. Write N/A if no one gets income from a job.

This

Next

Esimated total

month

month

income this year

JOB 1 Business name and address (include city and state)

Job start date (MM/YYYY): ______________

 

 

£ Self-employed? Type of work: _______________________ $

$

$

JOB 2 Business name and address (include city and state)

 

 

Job start date (MM/YYYY): ______________

 

 

£ Self-employed? Type of work: _______________________ $

$

$

JOB 3 Business name and address (include city and state)

 

 

Job start date (MM/YYYY): ______________

 

 

£ Self-employed? Type of work: _______________________ $

$

$

JOB 4 Business name and address (include city and state)

 

 

Job start date (MM/YYYY): ______________

 

 

£ Self-employed? Type of work: _______________________ $

$

$

JOB 5 Business name and address (include city and state)

 

 

Job start date (MM/YYYY): ______________

 

 

£ Self-employed? Type of work: _______________________ $

$

$

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

OHA 7210 (Rev 06/15)

13

STEP 3

 

INCOME AND DEDUCTIONS, coninued

 

 

 

 

3.OTHER INCOME: Some people receive income from other sources. Tell us if this person receives income from any of the sources listed below. Don’t include child support, veteran’s payments or Supplemental Security Income (SSI) because they are not taxable. Write N/A if no one gets other income.

 

This

Next

Esimated total

 

month

month

income this year

Unemployment. Name of state or employer paying: _____________

$

$

$

 

 

 

 

Reirement/pension

$

$

$

 

 

 

 

Capital gains

$

$

$

 

 

 

 

Investments

$

$

$

 

 

 

 

Net rental/royalty

$

$

$

 

 

 

 

Net farming/ishing

$

$

$

 

 

 

 

Prizes/awards/gambling

$

$

$

 

 

 

 

Alimony received

$

$

$

 

 

 

 

Per capita payments from casinos

$

$

$

 

 

 

 

Taxable Tribal income

$

$

$

 

 

 

 

Other taxable income

$

$

$

 

 

 

 

Social Security/SSDI (include both taxable and non-taxable amounts)

$

$

$

 

 

 

 

4.DEDUCTIONS: Some people can deduct certain things they pay for on their federal income tax return. Tell us about the following deducions this person claims on his/her taxes. Don’t include costs that were already deducted from self-employment income on the previous page. Write N/A if no one had deducions.

Alimony paid

Student loan interest

Educator expenses

IRA contribuions

Tuiion/fees

Other deducions

This

Next

Esimated total

month

month

deducions this year

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

 

 

 

14

Coninue to Step 4 if no one else has income.

YOU’RE ALMOST DONE WITH YOUR APPLICATION!

NEED HELP? Call us at 1-800-699-9075/TTY 711. Monday to Friday 7 a.m. to 6 p.m. OHA 7210 (Rev 06/15)

STEP 4

ADDITIONAL HOUSEHOLD QUESTIONS

 

 

Please answer quesions 1-2 for everyone listed on your applicaion, whether they are applying for health coverage or not, even if the answer is no. If you need more room, make a copy of this page before illing it out and atach it to your applicaion.

1.Is anyone pregnant? £ YES. If yes, give us their informaion. £ NO.

For "Due date", provide your best guess, even if you have not seen a doctor yet.

First/last name

Birthdate

(MM/DD/YYYY)

Due date

How many children are expected? Leave blank if unknown

2. Is anyone incarcerated? £ YES. If yes, give us their informaion. £ NO.

First/last name

Birthdate (MM/DD/YYYY)

Expected release date

Please answer quesions 3-9 only for people listed on your applicaion who are applying for health coverage, even if the answer is no.

3.Is anyone an enrolled member of a Federally recognized Tribe, Band, or Pueblo or a shareholder in a regional Alaska Naive Corporaion or Village? £ YES. If yes, give us their informaion. £ NO.

First/last name

Birthdate (MM/DD/YYYY)

Tribe name

4.Does anyone have a parent or grandparent who is an enrolled member of a Federally recognized Tribe, Band or Pueblo or a shareholder in a regional Alaska Naive Corporaion or Village AND/OR is anyone receiving or eligible to receive services from Indian Health Services, Tribal Health Clinics or Urban Indian Clinics? £ YES. If yes, give us their informaion. £ NO.

First/last name

Birthdate (MM/DD/YYYY)

NEED HELP? Call us at 1-800-699-9075/TTY 711. Monday to Friday 7 a.m. to 6 p.m. OHA 7210 (Rev 06/15)

15

 

STEP 4

ADDITIONAL HOUSEHOLD QUESTIONS, coninued

 

 

 

 

5. Is anyone legally blind? £ YES. If yes, give us their informaion. £ NO.

 

 

 

 

 

 

First/last name

 

Birthdate (MM/DD/YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.Does anyone have a disability that will last more than 12 months AND/OR does anyone need assistance with daily aciviies such as walking, eaing and remembering?

£ YES. If yes, give us their informaion. £ NO.

First/last name

Birthdate (MM/DD/YYYY)

7.Is anyone eligible for or receiving Supplemental Security Income (SSI)? £ YES. If yes, give us their informaion. £ NO.

First/last name

Birthdate (MM/DD/YYYY)

8. Is anyone 18 years old and a full-ime high school student? £ YES. If yes, give us their informaion. £ NO.

First/last name

Birthdate (MM/DD/YYYY)

9.Does anyone have any unpaid medical bills from the last 3 months OR has anyone received free medical services in the last 3 months? £ YES. If yes, give us their informaion. £ NO.

First/last name

Birthdate (MM/DD/YYYY)

16

NEED HELP? Call us at 1-800-699-9075/TTY 711. Monday to Friday 7 a.m. to 6 p.m. OHA 7210 (Rev 06/15)

STEP 5

CURRENT HEALTH INSURANCE

 

 

Is anyone who is applying for coverage covered by, ofered or eligible for health insurance? Answer yes even if they decided not to enroll due to cost, quality of coverage or another reason.

£YES. If yes, complete 1-3 for each person. £ NO. If no, skip to page 19 for Step 6.

First/last name: ____________________________________ Birthdate (MM/DD/YYYY): _______________

1. List the health insurance this person is covered by, ofered or eligible for:

a. Type of insurance: £ Private £ Employer £ COBRA £ Medicare £ TRICARE £ Peace Corps

£VA health care programs £ Reiree health plan

b. If known, expected: Start date: ______________________ End date:__________________

c. Is this person enrolled in the plan? £ YES. If yes, give the following informaion. £ NO

Insurance company name: __________________________________ Policy ID: ________________

Policyholder name: ______________________________ Policyholder birthdate:_______________

2.Is this person covered by health insurance but unable to use their health beneits?

£Yes, because of: £ Safety concerns £ Distance from providers £ Other reasons

£No

3.Is this person enrolled in Medicaid/CHIP in any state (e.g., Oregon Health Plan in Oregon)?

£ Yes. If yes, in which state? ____________________________ Expected end date:______________

£No

First/last name: ____________________________________ Birthdate (MM/DD/YYYY): _______________

1. List the health insurance this person is covered by, ofered or eligible for:

a. Type of insurance: £ Private £ Employer £ COBRA £ Medicare £ TRICARE £ Peace Corps

£VA health care programs £ Reiree health plan

b. If known, expected: Start date: ______________________ End date:__________________

c. Is this person enrolled in the plan? £ YES. If yes, give the following informaion. £ NO

Insurance company name: __________________________________ Policy ID: ________________

Policyholder name: ______________________________ Policyholder birthdate:_______________

2.Is this person covered by health insurance but unable to use their health beneits?

£Yes, because of: £ Safety concerns £ Distance from providers £ Other reasons

£No

3.Is this person enrolled in Medicaid/CHIP in any state (e.g., Oregon Health Plan in Oregon)?

£ Yes. If yes, in which state? ____________________________ Expected end date:______________

£No

NEED HELP? Call us at 1-800-699-9075/TTY 711. Monday to Friday 7 a.m. to 6 p.m. OHA 7210 (Rev 06/15)

17

STEP 5 CURRENT HEALTH INSURANCE, coninued

First/last name: ____________________________________ Birthdate (MM/DD/YYYY): _______________

1. List the health insurance this person is covered by, ofered or eligible for:

a. Type of insurance: £ Private £ Employer £ COBRA £ Medicare £ TRICARE £ Peace Corps

£VA health care programs £ Reiree health plan

b. If known, expected: Start date: ______________________ End date:__________________

c. Is this person enrolled in the plan? £ YES. If yes, give the following informaion. £ NO

Insurance company name: __________________________________ Policy ID: ________________

Policyholder name: ______________________________ Policyholder birthdate:_______________

2.Is this person covered by health insurance but unable to use their health beneits?

£Yes, because of: £ Safety concerns £ Distance from providers £ Other reasons

£No

3.Is this person enrolled in Medicaid/CHIP in any state (e.g., Oregon Health Plan in Oregon)?

£ Yes. If yes, in which state? ____________________________ Expected end date:______________

£No

First/last name: ____________________________________ Birthdate (MM/DD/YYYY): _______________

1. List the health insurance this person is covered by, ofered or eligible for:

a. Type of insurance: £ Private £ Employer £ COBRA £ Medicare £ TRICARE £ Peace Corps

£VA health care programs £ Reiree health plan

b. If known, expected: Start date: ______________________ End date:__________________

c. Is this person enrolled in the plan? £ YES. If yes, give the following informaion. £ NO

Insurance company name: __________________________________ Policy ID: ________________

Policyholder name: ______________________________ Policyholder birthdate:_______________

2.Is this person covered by health insurance but unable to use their health beneits?

£Yes, because of: £ Safety concerns £ Distance from providers £ Other reasons

£No

3.Is this person enrolled in Medicaid/CHIP in any state (e.g., Oregon Health Plan in Oregon)?

£ Yes. If yes, in which state? ____________________________ Expected end date:______________

£No

18

NEED HELP? Call us at 1-800-699-9075/TTY 711. Monday to Friday 7 a.m. to 6 p.m. OHA 7210 (Rev 06/15)

STEP 6

READ AND SIGN

 

 

I’m signing this applicaion under penalty of perjury, which means I’ve provided true answers to all the quesions on this form to the best of my knowledge. I know I may be subject to penalies or be liable for overpayments under federal law if I provide false and or untrue informaion.

I know I must tell the Oregon Health Authority (OHA) if anything changes and is diferent from what I wrote on this applicaion. I can call 1-800-699-9075 to report any changes. I understand that a change in my informaion could afect the eligibility for member(s) of my household.

I know that under federal law, discriminaion isn’t permited on the basis of race, color, naional origin, sex, age, sexual orientaion, gender idenity or disability. I can ile a complaint of discriminaion by visiing www.hhs.gov/ocr/oice/

I have read the Applicaion Guide and agree to all secions. (You can ind the Applicaion Guide online at www.OHP.oregon.gov.)

State law says that all individuals receiving Oregon Health Plan (OHP) automaically give OHA the right to payments from others that were legally liable to pay some or all medical expenses for those individuals. This includes other health insurance, liability insurance or other individuals. It also includes any payments that are due to you because another person injured you. The right to the payment will not exceed the amount paid by OHP or your coordinated care organizaion.

I agree to noify OHA (or its designee) and my coordinated care organizaion when I am pursuing a claim against anyone who injured me or another member of my family who receives OHP and, when requested, to provide informaion that is needed to get the reimbursements.

USE OF SOCIAL SECURITY NUMBER (SSN)

These federal laws say that anyone applying for medical beneits must provide an SSN: Federal laws - 42 USC 1320b-7(a), 7 USC 2011-2036, 42 CFR 435.910, 42 CFR 435.920, 42 CFR 457.340(b). When you write your SSN on the applicaion it means you give permission to OHA to use it and tell others about it for these reasons:

To help us decide if you qualify for beneits. We will use the SSNs you provide to make sure the income and assets you listed on this applicaion are correct. We will match informaion from other state and federal records, such as the Internal Revenue Service, Department of Revenue, Medicaid, child support, Social Security and unemployment beneits.

To write reports about the Oregon Health Plan.

To administer the program you apply for or receive beneits from, if necessary.

To help us improve programs by doing quality reviews and other aciviies.

To make sure we have given you the correct amount of beneits and to recover money if we have overpaid beneits.

YOUR RIGHT TO A HEARING

If you disagree with the decisions OHA makes regarding your eligibility or you do not get a decision from us within 45 days, you have the right to request a hearing. You also have the right to choose an authorized representaive to act on your behalf during the hearing process.

We encourage you to call us at 1-800-699-9075 to ask quesions about your eligibility or the process, or provide us with addiional informaion about yourself and/or your household.

If you want a hearing, you must request it within 90 days of the date on the eligibility noice you will receive (in the mail or email). Your deadline to request a hearing does not change even if you contact us.

NEED HELP? Call us at 1-800-699-9075/TTY 711. Monday to Friday 7 a.m. to 6 p.m. OHA 7210 (Rev 06/15)

19

STEP 6

READ AND SIGN, coninued

DID AN AGENT OR COMMUNITY PARTNER HELP YOU?

If a ceriied insurance agent or community partner helped you with this applicaion, please provide his/her informaion.

Agent/Assister name

Organizaion name

Assister ID

Date of request (Oicial use only)

ACCESS TO INCOME DATA IN FUTURE YEARS

To see if you qualify for Oregon Health Plan coverage in future years, you can give the Oregon Health Authority (OHA) ongoing permission to access your income data (including your tax returns, in some cases). If you choose to do this, you can opt out at any ime by contacing us at 1-800-699-9075. You can also update the income informaion you provided on this applicaion at any ime. Would you like to allow OHA to access your income informaion in future years? £ Yes £ No

NOT REGISTERED TO VOTE WHERE YOU LIVE NOW?

If you are not registered to vote where you live now, would you like to register to vote today? £ Yes £ No.

Applying to register, or declining to register to vote will not afect the amount of assistance you will be provided by this agency.

SIGN THIS APPLICATION

The primary contact who completed Step 1 should sign this applicaion. By signing this applicaion, you conirm that you have permission from all people on this applicaion to both submit their informaion and receive communicaions about their eligibility and enrollment.

If you have an authorized representaive, that person may sign for you. If you are an authorized representaive you may sign here only if you and the applicant have completed and signed the Authorized Representaive form (Appendix B).

Printed name

Signature

Date (MM/DD/YYYY)

SUPPLEMENTAL PAGES: APPENDIX A, B and C

Use Appendix A to choose a coordinated care organizaion and/or dental plan. If you do not choose a CCO now, you will be automaically enrolled into a plan in your area.

Use Appendix B to choose and tell us about your authorized representaive if you have one. You will need to complete this form before your authorized representaive can sign the applicaion and/or talk to OHA on your behalf.

Use Appendix C to authorize a Community Partner Organizaion to see and use your personal informaion to help you apply for health coverage.

HOW TO SEND YOUR APPLICATION

Send your signed applicaion to us by mail or fax.

Mail

OHP Customer Service

 

P.O. Box 14520

 

Salem, OR 97309-5044

Fax:

503-373-7493

CONGRATULATIONS, YOU’RE DONE! WHAT HAPPENS NEXT?

We’ll let you know what you and your family qualify for soon. If you don’t hear from us within 45 days, call 1-800-699-9075.

20

NEED HELP? Call us at 1-800-699-9075/TTY 711. Monday to Friday 7 a.m. to 6 p.m. OHA 7210 (Rev 06/15)

APPENDIX A

CHOOSE A COORDINATED CARE ORGANIZATION (CCO) AND/OR DENTAL PLAN

Most OHP members are enrolled in a CCO and/or a dental plan in their area.

A CCO is a local network of all types of healthcare providers that include physical health, addicions and mental health, and, someimes, dental care providers. These providers work together in their communiies to serve OHP members.

You can tell us your irst and second choices for CCO/dental plans below. To ind a list of plans in your area and to ind out more about them, go to www.OHP.Oregon.gov. You may want to ask your provider(s) which plans they accept. In addiion, diferent CCO/dental plan enrollment opions apply to individuals who receive Medicare. Please see the Applicaion Guide for more informaion if you receive Medicare.

Note: Tribal informaion for people who qualify for OHP

Please note the following for any household member who: 1) is an enrolled Tribal member, 2) has a parent or grandparent who is an enrolled Tribal member, and/or 3) is eligible for services at Indian Health Services, Tribal Health Clinics and Urban Indian Clinics:

If you qualify for OHP, you will be covered by an open card, UNLESS you choose to enroll in a CCO/dental plan (if available) by entering your choices below. If you do not want to enroll in a CCO/dental plan, do not enter anything in the boxes below.

You can sill get care through Indian Health Services, Tribal Health Clinics and Urban Indian Clinics whether you‘re enrolled in a CCO/dental plan or on an open card.

CHOOSE A CCO AND/OR A DENTAL PLAN

Use the boxes below to tell us which CCO/dental plans you prefer. You are not required to choose a CCO/dental plan now. But, if you do not make a choice now, a plan will be selected for you based on where you live (unless the Tribal excepions listed above apply to you).

If your choices are not available, you may be contacted to choose a diferent CCO/dental plan.

CCO – 1st choice:

CCO – 2nd choice:

Dental plan – 1st choice:

Dental plan – 2nd choice:

Please refer to the Applicaion Guide for more informaion about choosing a plan.

NEED HELP? Call us at 1-800-699-9075/TTY 711. Monday to Friday 7 a.m. to 6 p.m. OHA 7210 (Rev 06/15)

21

APPENDIX B

AUTHORIZED REPRESENTATIVE

You can choose an authorized representaive to talk to the Oregon Health Authority. If you’d like to choose an authorized representaive, please use this form to tell us about the person you have chosen. You and your authorized representaive must sign this form in order for the authorized representaive to be conirmed and approved. If you designated an authorized representaive before, the person listed below will replace them.

1.You can choose an individual or an organizaion to be your authorized representaive. If your authorized representaive is an: £ Individual, complete a. £ Organizaion, complete b.

a. Individual: Legal name (irst, middle, last and suix) ________________________________________

Birthdate (MM/DD/YYYY) _____________________

b. Organizaion: Organizaion name _______________________________________________________

Organizaion contact name (irst, middle, last and suix) ___________________________________

Organizaion contact birthdate (MM/DD/YYYY) ___________________________

2.

Mailing address

 

 

3. Apartment/Unit #

 

 

 

 

 

 

4.

City

 

5. State

 

6. ZIP code

 

 

 

 

 

7.

Email address

8. Authorizaion start and end date:

 

 

Start: ___________

End: ___________

 

 

 

 

 

 

9.

Tell us who the authorized representaive can get informaion about:

 

 

 

 

All people listed on my applicaion Primary contact Person 2 Person 3 Person 4

10.Tell us what the authorized representaive can do for those individuals selected in #9 (check all that apply):

Sign an applicaion on their behalf Complete and submit a renewal form

Act on behalf of those individuals in any and all maters with the Agency

Receive copies of noices and other communicaions from the Agency for those individuals

11.How are you associated with the authorized representaive:

Power of Atorney Lawyer Legal Guardianship Health Care Representaive

Community Partner (Applicaion Assisters) Other: _______________________________________

12.Print applicant name

14.Applicant Signature

13.Applicant birthdate

15.Date

AUTHORIZED REPRESENTATIVE: By signing below, I understand that I am liable for repayment of an overpayment if I knowingly withhold or give incorrect or incomplete informaion. I also understand that I must maintain the conideniality of any informaion provided by the Oregon Health Authority, regarding the applicant and anyone listed on the applicaion.

16. Print authorized representaive name

17. Authorized representaive signature

Date

You can return this form with your applicaion or send it separately by:

Fax to 503-373-7493 or

Mail to OHP Customer Service, PO Box 14520, Salem, OR 97309-5044

22

OHA 0232 (11/14)

NEED HELP? Call us at 1-800-699-9075/TTY 711. Monday to Friday 7 a.m. to 6 p.m. OHA 7210 (Rev 06/15)

APPENDIX C

COMMUNITY PARTNER ASSISTANCE CONSENT

COMMUNITY PARTNER ORGANIZATION INFORMATION

1. Community Partner Organizaion

2. Applicaion Assister name

3. Assister ID#

 

 

 

4. Address

5. City

6. State

7. ZIP code

APPLICANT INFORMATION

8. Name (irst, middle, last)

 

9. Date of birth

10. Phone #

 

11. Email address

 

 

 

 

 

 

 

 

 

 

12.

Address

 

 

13. City

14. State

15. ZIP code

 

 

 

 

 

 

 

16.

Total # of household

17. # of household members

18. Names of other adults on your applicaion

 

members

over 18

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPLICANT: I authorize the Community Partner Organizaion listed above to see and use my personal informaion to help me apply for health coverage. The Community Partner Organizaion will make sure any stored personal informaion is kept private and secure.

If applying for or enrolling in a Public Medical Program (includes the Oregon Health Plan, CAWEM and CAWEM Plus): I authorize the Oregon Health Authority to disclose my applicaion, enrollment details and status, to the Community Partner Organizaion listed above, for the purpose of assising me in applying for and enrolling in health coverage. I authorize the Oregon Health Authority to add this Community Partner Organizaion to my case ile conirming this permited disclosure.

The individual Applicaion Assister associated with the Community Partner Organizaion listed above WILL:

Inform me about what health insurance and inancial help I may qualify for;

Help me enroll in and disclose my applicaion informaion to a Public Medical Program or a Qualiied Health Plan (QHP);

Help me in the language I prefer or refer me to other partners who can help me in the language I speak/understand.

I understand that the Community Partner Organizaion and the individual Applicaion Assister may NOT:

Charge me a fee for any assistance provided;

Choose or recommend a health insurance plan for me.

I understand that I am responsible for reporing accurate informaion on this applicaion and for responding to any noice of missing or inaccurate informaion, as needed.

I may revoke this authorizaion at any ime by calling the Oregon Health Authority at 1-800-699-9075 or by faxing my request to 503-373-7493.

19. Signature

Date

20. This authorizaion is valid for one year from the date of signing unless otherwise speciied here:

If you have an authorized representaive, that person may sign for you. If you are an authorized representaive you may sign here only if you and the applicant have completed and signed the Authorized Representaive form (Appendix B).

You can return this form with your applicaion or send it separately by:

Fax to 503-373-7493 or

Mail to OHP Customer Service, PO Box 14520, Salem, OR 97309-5044

DMAP 6610 (Rev 01/15)

NEED HELP? Call us at 1-800-699-9075/TTY 711. Monday to Friday 7 a.m. to 6 p.m. OHA 7210 (Rev 06/15)

23

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