Health Coverage Request

How would you like to get information about this Request?
Is this person applying for health care coverage?
(For individuals not applying for coverage, providing a Social Security number (SSN) or citizenship status is optional)
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:
Does anyone claim you as a dependent on their taxes?
Are you going to file taxes for the benefit year?
Expected tax filing status for the current year (select one)
RACE / ETHNICITY CODE (OPTIONAL – check all that apply) If American Indian or Alaska Native, do not enter a race or ethnicity
Do you receive Medicare benefits?