CMS-10440 CMS_10440_AttachmentD-Application for Health Coverage

Data Collection to Support Eligibility Determinations for Insurance Affordability Programs and Enrollment through Health Benefits Exchanges, Medicaid and Children's Health Insurance Program Agencies

CMS-10440.AttachmentD-Application for Health Coverage

Individual Application

OMB: 0938-1191

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-1191 can be found here:

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04.24.13

THINGS TO KNOW

Application for Health Coverage
Who can use this
application?

Anyone who needs health coverage can use this application.

Apply faster
online

Apply faster online at HealthCare.gov.

What happens
next?

Send your complete, signed application to the address on
page 3. (If you don’t have all the information we ask for,
sign and submit your application anyway.)

If someone is helping you fill out this application, you may
need to complete Appendix C.

We’ll follow up with you within 1–2 weeks to let you know
how to join a health plan.
Filling out this application doesn’t mean you have to buy
health coverage.

Get help with
costs

You need to use a different application to get help with
costs. You could qualify for:

Get help with
this application

• ONLINE: HealthCare.gov.

• A new tax credit that can immediately help pay your
premiums for health coverage
• Free or low-cost coverage from Medicaid or the Children’s
Health Insurance Program (CHIP)
You may qualify for a free or low-cost program even if you
earn as much as $94,000 a year (for a family of 4). Visit
HealthCare.gov or call 1-800-XXX-XXXX to learn more.

• PHONE: Call our Help Center at 1-800-XXX-XXXX.
• IN PERSON: There may be counselors in your area who
can help. Visit HealthCare.gov or call 1-800-XXX-XXXX for
more information.
• EN ESPAÑOL: Llame a nuestro centro de ayuda gratis al
1-800-XXX-XXXX.

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-800-XXX-XXXX. Para obtener una copia de este
formulario en Español, llame 1-800-XXX-XXXX. If you need help in a language other than English, call 1-800-XXX-XXXX and tell the
customer service representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-800-XXX-XXXX.

STEP 1

Tell us about yourself.

(We’ll need one adult in the family to be the contact person for your application.)
1. First name, Middle name, Last name, & Suffix
2. Home address (Leave blank if you don’t have one.)
4. City

3. Apartment or suite number
5. State

6. ZIP code

7. County

8. Mailing address (if different from home address)
10. City

9. Apartment or suite number
11. State

14. Phone number

(

)

12. ZIP code

13. County

15. Other phone number

–

(

16. Do you want to get information about this application by email?

)
Yes

–
No

Email address:
17. Preferred spoken or written language (if not English)

18. Do you need health coverage?

Yes. If yes, answer all the questions below.
No. If no, skip to Step 2 on page 2. (Leave the rest of this page blank)

19. Social Security number

20. Sex

Male

We need Social Security Numbers (SSNs) for anyone who wants coverage. We use
SSNs to verify citizenship. If someone doesn’t have an SSN, visit socialsecurity.gov or
call 1-800-772-1213. TTY users should call 1‑800‑325‑0778.

Female

21. Date of birth (mm/dd/yyyy)
22. Are you a U.S. citizen or U.S. national?

Yes

23. If you aren’t a U.S. citizen or U.S. national, do you have eligible immigration status?
Yes. Fill in your document type and ID number below.
Immigration document type

Document ID number

NOW, tell us who else needs health coverage.

STEP 2

Tell us about anyone who needs health coverage.
(If you have more people to include, make a copy of this page and attach.)

STEP 2: PERSON 2
1. First name, Middle name, Last name, & Suffix
3. Social Security number

2. Relationship to you?

4. Date of birth (mm/dd/yyyy) 5. Sex

6. Does PERSON 2 live at the same address as you?
7. Is PERSON 2 a U.S. citizen or U.S. national?

Yes

Male

Female

If no, list address:

8. If PERSON 2 isn’t a U.S. citizen or U.S. national, do they have eligible immigration status?
Yes. Fill in PERSON 2’s document type and ID number below:
Immigration document type

Document ID number

STEP 2: PERSON 3
1. First name, Middle name, Last name, & Suffix
3. Social Security number

2. Relationship to you?

4. Date of birth (mm/dd/yyyy) 5. Sex

6. Does PERSON 3 live at the same address as you?
7. Is PERSON 3 a U.S. citizen or U.S. national?

Yes

Male

Female

If no, list address:

8. If PERSON 3 isn’t a U.S. citizen or U.S. national, do they have eligible immigration status?
Yes. Fill in PERSON 3’s document type and ID number below.
Immigration document type

Document ID number

STEP 2: PERSON 4
1. First name, Middle name, Last name, & Suffix
3. Social Security number

2. Relationship to you?

4. Date of birth (mm/dd/yyyy) 5. Sex

6. Does PERSON 4 live at the same address as you?
7. Is PERSON 4 a U.S. citizen or U.S. national?

Yes

Male

Female

If no, list address:

8. If PERSON 4 isn’t a U.S. citizen or U.S. national, do they have eligible immigration status?
Yes. Fill in PERSON 4’s document type and ID number below:
Immigration document type

Document ID number

STEP 3

American Indian or Alaska Native (AI/AN) family member(s)

1. Are you or is anyone in your family American Indian or Alaska Native?
No. If no, skip to Step 4.

Yes. If yes, continue. If you have more people to include,
make a copy of this page and attach.
AI/AN PERSON 1

2. Name

First

Middle

AI/AN PERSON 2
First

Middle

(First name, Middle name, Last name)

3. Member of a federally recognized tribe?

Last

Yes
If yes, tribe name

________________________________________________________

STEP 4

Read & sign this application.

•

I’m signing this application under penalty of perjury, which means I’ve provided true answers to all of
the questions to the best of my knowledge. I know that I may be subject to penalties under federal law
if I intentionally provide false or untrue information.

•

I know that I must tell the Health Insurance Marketplace if anything changes (and is different than) what I
wrote on this application. I can visit HealthCare.gov or call 1-800-XXX-XXXX to report any changes.
I understand that a change in my information could affect the eligibility for member(s) of my household.

•

I know that under federal law, discrimination isn’t permitted on the basis of race, color, national origin,
sex, age, sexual orientation, gender identity, or disability. I can file a complaint of discrimination by
visiting www.hhs.gov/ocr/office/file.

•

I know that my information on this form will only be used to determine eligibility for health coverage
and will be kept private as required by law.

•

I confirm that no one applying for health coverage on this application is incarcerated (detained or
jailed). If not, ______________________________is incarcerated.
(name of person)

•

I understand that my information will be used to check eligibility for health coverage.
We’ll check your answers using information in our electronic databases and databases from Social Security and
the Department of Homeland Security. If the information doesn’t match, we may ask you to send us proof.

Sign this application. The person who filled out Step 1 should sign this application. If you’re an authorized
representative, you may sign here as long as you have provided the information required in Appendix C.
Signature

STEP 5

Date (mm/dd/yyyy)

Mail completed application.

Mail your signed application to:

Health Insurance Marketplace
1005 XYZ Drive
Washington, DC 20005
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0938-XXXX. The time required to complete this information collection is estimated
to average [Insert Time (hours or minutes)] per response, including the time to review instructions, search existing data resources, gather the data needed,
and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving
this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

04.23.13

APPENDIX C
Assistance with Completing this Application
You can choose an authorized representative.
You can give a trusted person permission to talk about this application with us, see your information, and act for you on
matters related to this application, including getting information about your application and signing your application
on your behalf. This person is called an “authorized representative.” If you ever need to change your authorized
representative, contact the Marketplace. If you’re a legally appointed representative for someone on this application,
submit proof with the application.
1. Name of authorized representative (First name, Middle name, Last name)
2. Address

3. Apartment or suite number

4. City

5. State

7. Phone number

(

)

6. ZIP code

–

8. Organization name

9. ID number (if applicable)

By signing, you allow this person to sign your application, get official information about this application, and act for you
on all future matters with this agency.
10. Your signature

11. Date (mm/dd/yyyy)

For certified application counselors, navigators, agents, and brokers only.
Complete this section if you’re a certified application counselor, navigator, agent, or broker filling out this application for
somebody else.
1. Application start date (mm/dd/yyyy)
2. First name, Middle name, Last name, & Suffix
3. Organization name

4. ID number (if applicable)

File Type	application/pdf
File Title	AppendixC_042313.pdf
File Modified	2013-04-24
File Created	2013-04-24