Individual Application

Data Collection to Support Eligibility Determinations for Insurance Affordability Programs and Enrollment through Health Benefits Exchanges, Medicaid and CHIP Agencies (CMS-10440)

OMB: 0938-1191

IC ID: 205692

Documents and Forms

Document Name Document Type
CMS-10440 Application for Health Coverage & Help Paying Costs (Short Form) Att B-Individual-short-form-English clean FINAL.pdf Form and Instruction
CMS-10440 Application for Health Coverage & Help Paying Costs Att C-Marketplace-consumer-application-family-English-clean-Final.pdf Form and Instruction
CMS-10440 Application for Health Coverage (no cost help) Att D-Marketplace-application-without-financial-assistance-English clean FINAL.pdf Form and Instruction
CMS-10440 Electronic application. CMS-10440 - Att A.-App3 PRA Electronic Application - Final.xlsx Form
CMS-10440 Attachment B - Individual Short Form (Spanish) Att B-Individual-short-form-Spanish-clean_FINAL.pdf Form and Instruction
CMS-10440 Attachment C - Marketplace Consumer Application (Spanish) Att C-Marketplace-consumer-application-family-Spanish-clean FINAL.pdf Form and Instruction
CMS-10440 Attachment D - Marketplace Application without Financial Assistance (Spanish) Att D-Marketplace-application-without-financial-assistance_Spanish-clean FINAL.pdf Form and Instruction