Document
Application for Health Coverage and Help Paying Costs Short Form
ICR 202506-0938-003 · OMB 0938-1191 · Object 158544301.
This document may belong to an older filing. More recent activity for OMB 0938-1191:
Document Viewer [pdf]
Status: Original and derived artifacts are available for this document.
Download: pdf
Loading document viewer…
Document Metadata
| File Type | application/octet-stream |
|---|---|
| File Title | Application for Health Coverage and Help Paying Costs Short Form |
| Subject | Application for Health Coverage and Help Paying Costs (Short Form), Health Insurance Marketplace |
| Author | Centers for Medicare and Medicaid Services |
| File Modified | 2025-02-21 |
| File Created | 2023-09-25 |
| Conversion State | complete |