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.

Question	Answer
Form Name	Oha 7210
Form Length	25 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	6 min 15 sec
Other names	oregon application health form, 7210 or application, medicaid renewal application 7210, oregon application health plan form

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:
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)	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)	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)	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)	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)	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)	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)	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)	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)	10
	OHA 7210 (Rev 09/16)

How to Edit Oha 7210 Online for Free

This PDF editor was made to be so simple as possible. While you keep up with these steps, the procedure for filling out the 7210 or application file will undoubtedly be effortless.

Step 1: Hit the button "Get form here" to open it.

Step 2: Now you will be on your document edit page. You'll be able to add, transform, highlight, check, cross, add or erase areas or phrases.

For you to get the form, provide the data the program will require you to for each of the following areas:

Type in the demanded details in the STEP, Legal name first middle last and, Maiden or other names used first, Social Security number SSN An, SSN, No Applied for SSN Newborn Dont, Birthdate MMDDYYYY, Sex, Phone number Home Work Cell, Male Female, Do you live in Oregon Answer yes, Only answer if you are applying, Email address, Home address skip to if you dont, and ApartmentUnit segment.

The program will require details to instantly fill in the box Mailing address only required if, ApartmentUnit, City, State, and ZIP code.

In the field STEP, Primary Contact continued, In what language do you want us, In what language do you want us, Do you need written materials in, If yes which Braille Oral, Are you pregnant Yes No Is, Do you the primary contact plan, plan to file even if you will not, YES If yes complete ab below NO, What will your filing status be on, Single Head of household, If married spouses name, Do you have any tax dependents, and Firstlast name and birthdate of, list the rights and obligations of the parties.

Check the areas Note for each person listed as a, Are you claimed as a dependent on, If yes list firstlast name and, How are you related to the tax, If HispanicLatino ethnicity, Mexican Mexican American, Race check all that apply, American Indian or Alaska Native, Filipino Guamanian or Chamorro, Other Pacific Islander Samoan, Is your tax filing information, YES NO If no complete Appendix D, Are you applying for health, coverage, and YES If yes go to NO If no skip and thereafter fill them in.

Step 3: Once you've clicked the Done button, your document is going to be available for upload to every gadget or email address you identify.

Step 4: It may be simpler to keep duplicates of your document. You can be sure that we will not share or see your data.

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