subject_line
Health Coverage Request
Primary
First Name
Last name
Date of Birth
+
Address
State
AL
AR
AZ
CA
CO
FL
GA
IN
IL
KS
MI
MO
MS
NE
NC
NJ
NH
NM
NV
OH
OK
PA
SC
TN
TX
UT
VA
WA
WI
Zip
Mailing address (If different)
Sex
FEMALE
MALE
Contact Number
(Secondary) Contact Number
Email
How would you like to get information about this Request?
Phone
Email
USPS Mail
Is this person applying for health care coverage?
Yes
No If no, SSN information is optional.
Social Security number
(For individuals not applying for coverage, providing a Social Security number (SSN) or citizenship status is optional)
U.S. citizen or U.S. national
Non-citizen lawfully present in the U.S.
Other
If you are a lawfully present non-citizen, enter the following information:
Include the document type, your “A” number and receipt number or other immigration number:
Immigration document type:
“A” number:
Receipt number or other number:
Foreign passport number:
Country of issuance:
Date of entry:
+
Document expiry date:
+
Does anyone claim you as a dependent on their taxes?
Yes
No
Are you going to file taxes for the benefit year?
Yes
No
Expected tax filing status for the current year (select one)
Single filing taxes
Head of household
Qualifying widow(er) with dependent child
Married filing separately
Tax dependent of someone on the application
Tax dependent of someone not on the application
Person has neither filed taxes nor was tax dependent
Married filing jointly: Name of primary tax filer:
Married filing jointly: Name of primary tax filer:
RACE / ETHNICITY CODE (OPTIONAL – check all that apply) If American Indian or Alaska Native, do not enter a race or ethnicity
White
Black
African American
Asian
Native Hawaiian
Pacific Islander
Hispanic or Latino
Other
Other
Do you receive Medicare benefits?
Yes
No