Health Insurance Enrollment Form for Healthcare.gov (Obamacare)

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Form Approved
OMB No. 0938-1191
Application for Health Coverage & Help Paying Costs (Short Form)
Use this application * Affordableprivatehealthinsuranceplansthatoffercomprehensive
to see what
coverage to help you stay well
coverage you
* A new tax credit that can immediately help pay your premiums for health
coverage
qualify for
* Free or low-cost insurance from Medicaid or the Children's Health
Insurance Program (CHIP)
Who can use this
Single adults who:
application?
* Aren'tofferedhealthcoveragefromtheiremployer
* Don't have any dependents and can't be claimed as a dependent on
someone else's tax return
NOTE:Ifanyofthefollowingapply,youneedtofilloutadifferentformto
makesureyougetthemostbenefitspossible:
* You're married or have dependent children.
* You were in the foster care system, and you're under age 26.
* You have items that can be deducted from your income. If your only
deduction is student loan interest, you can use this form.
* You're American Indian or Alaska Native.
KNOW
Apply faster
Apply faster online at HealthCare.gov.
online
TO
What you may
* Your Social Security number (or document number if you're an eligible
need to apply
immigrant)
THINGS
* Employer and income information (for example, from paystubs,
W-2 forms, or wage and tax statements)
Why do we ask for
We ask about income and other information to let you know what coverage
this information?
you qualify for and if you can get any help paying for it.
We'll keep all the information you provide private and secure, as
required by law. To view the Privacy Act Statement, go to HealthCare.gov.
What happens
Send your complete, signed application to the address on page 3. If you
next?
don't have all the information we ask for, sign and submit your
application anyway. We'll follow up with you within 1-2 weeks. Filling out
this application doesn't mean you have to buy health coverage.
Get help with this
* Online: HealthCare.gov
application
* Phone: Call our Help Center at 1-800-318-2596.
* In person: There may be counselors in your area who can help.
Visit HealthCare.gov or call 1-800-318-2596 for more information.
* En Espanol: Llame a nuestro centro de ayuda gratis al 1-800-318-2596.
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 0938-1191. The time required to complete this information collection is estimated
to average 15 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.
NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-800-318-2596. Para obtener una copia de este formulario en
Espanol, llame 1-800-318-2596. If you need help in a language other than English, call 1-800-318-2596 and tell the customer service representative
the language you need. We'll get you help at no cost to you. TTY users should call 1-855-889-4325.

Initial here:
Use blue or black ink to complete this application.
Page 1 of 3
STEP 1 Tell us about yourself.
(We 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.)
3. Apartment or suite number
4. City
5. State
6. ZIP code
7. County
8. Mailing address (if different from home address)
9. Apartment or suite number
10. City
11. State
12. ZIP code
13. County
14. Phone number
15. Other phone number
(
)
-
(
)
-
16. Do you want to get information about this application by email?
Yes
No
Email address:
17. What is your preferred spoken or written language (if not English)?
18. Date of birth (mm/dd/yyyy)
19. Sex
/
/
Male
Female
20. Social Security number (SSN)
-
-
We need this if you want health coverage and have an SSN. We use SSNs to check income and other information to see if you're eligible
for help with health coverage costs. If you need help getting an SSN, call 1-800-772-1213 or visit socialsecurity.gov. TTY users should call
1-800-325-0778.
21. Are you a U.S. citizen or U.S. national?
Yes
No
22. If you aren't a U.S. citizen or U.S. national, do you have eligible immigration status? (See instructions.)
Yes. Fill in your document type and ID number below.
a. Immigration document type:
b. Document ID number
c. Have you lived in the U.S. since 1996?
d. Are you a veteran or an active-duty member of the U.S. military?
Yes
No
Yes
No
23. Are you pregnant?
Yes
No a. If yes, how many babies are expected during this pregnancy?
24. Do you have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc.)
or live in a medical facility or nursing home?
Yes
No
25. If Hispanic/Latino, ethnicity (OPTIONAL--check all that apply.)
Mexican
Mexican American
Chicano/a
Puerto Rican
Cuban
Other
26. Race (OPTIONAL--check all that apply.)
White
American Indian or
Filipino
Vietnamese
Guamanian or Chamorro
Black or African
Alaska Native
Japanese
Other Asian
Samoan
American
Asian Indian
Korean
Native Hawaiian
OtherPacificIslander
Chinese
Other
NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-800-318-2596. Para obtener una copia de este formulario en
Espanol, llame 1-800-318-2596. If you need help in a language other than English, call 1-800-318-2596 and tell the customer service representative
the language you need. We'll get you help at no cost to you. TTY users should call 1-855-889-4325.

Initial here:
Page 2 of 3
STEP 2 Current job & income information
Employed: If you're currently employed, tell us about
Not employed: Skip to question 11.
your income. Start with question 1..
Self-employed: Skip to question 10.
CURRENT JOB 1:
1. Employer name
a. Employer address
b. City
c. State
d. ZIP code
2. Employer phone number
(
)
-
3. Wages/tips (before taxes)
4. Average hours worked each WEEK
Hourly
Weekly
Every 2 weeks
$
Twice a month
Monthly
Yearly
CURRENT JOB 2: (If you have more jobs and need more space, attach another sheet of paper.)
5. Employer name
a. Employer address
b. City
c. State
d. ZIP code
6. Employer phone number
(
)
-
7. Wages/tips (before taxes)
8. Average hours worked each WEEK
Hourly
Weekly
Every 2 weeks
$
Twice a month
Monthly
Yearly
9. In the past year, did you:
Change jobs
Stop working
Start working fewer hours
None of these
10. If self-employed, answer the following questions:
a. Type of work:
b. How much net income (profits once business expenses are paid) will you get from
this self-employment this month? (See instructions.)
$
11. OTHER INCOME THIS MONTH: Check all that apply, and give the amount and how often you get it.
NOTE: You don't need to tell us about child support, veteran's payment, or Supplemental Security Income (SSI).
None
Retirement accounts
$
How often?
Unemployment $
How often?
Alimony received
$
How often?
Pension
$
How often?
Net farming/fishing
$
How often?
Social Security
$
How often?
Other income
$
How often?
Type:
12. Do you pay student loan interest (not the amount of the loan) that can be deducted on a federal income tax return?
YES. If yes, how much $
How often?
NO.
13. YEARLY INCOME: Complete only if your income changes from month to month. If you don't expect changes to your monthly
income, skip to Step 3.
Your total income this year
Your total income next year(ifyouthinkitwillbedifferent)
$
$
NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-800-318-2596. Para obtener una copia de este formulario en
Espanol, llame 1-800-318-2596. If you need help in a language other than English, call 1-800-318-2596 and tell the customer service representative
the language you need. We'll get you help at no cost to you. TTY users should call 1-855-889-4325.

Initial here:
Page 3 of 3
STEP 3 Your health coverage
1. Are you enrolled in health coverage now from the following?
YES. If yes, check which coverage you have.
NO.
Medicaid
VA health care program
CHIP
Other
Medicare
Name of health insurance:
TRICARE(Don'tcheckifyouhaveDirectCareorLineofDuty)
Policy number:
Peace Corps
STEP 4 Read & sign this application.
* I'm signing this application under penalty of perjury, which means
Yes, renew my eligibility automatically for the next
I've provided true answers to all the questions on this form to the
5years(themaximumnumberofyearsallowed),orfora
best of my knowledge. I know that I may be subject to penalties
shorter number of years:
under federal law if I intentionally provide false or untrue
4 years
3 years
2 years
1 year
information.
Don'tuseinformationfromtaxreturnstorenewmycoverage.
* I know that I must tell the Health Insurance Marketplace if anything
changes(andisdifferentthan)whatIwroteonthisapplication.
If I'm eligible for Medicaid
I can visit HealthCare.gov or call 1-800-318-2596 to report any
If I enroll in Medicaid, I'm giving the Medicaid agency my rights
changes.Iunderstandthatachangeinmyinformationcouldaffect
to pursue and get any money from other health insurance, legal
my eligibility.
settlements, or other third parties.
* I know that under federal law, discrimination isn't permitted on the
What should I do if I think my eligibility results are wrong?
basis of race, color, national origin, sex, age, sexual orientation,
genderidentity,ordisability.Icanfileacomplaintofdiscrimination
If you don't agree with what you qualify for, in many cases, you can
by visiting www.hhs.gov/ocr/office/file.
askforanappeal.Pleasereviewyoureligibilitynoticetofindappeals
instructionsspecifictoeachpersoninyourhousehold,including
* I know that my information on this form will be used only to
how many days you have to request an appeal. Below is important
determine eligibility for health coverage and will be kept private as
information to consider when requesting an appeal:
required by law.
* You can have someone request or participate in your appeal if
* IconfirmthatI'mnotincarcerated(detainedorjailed).
you want to. That person can be a friend, relative, lawyer, or other
* IconfirmthatnextyearIexpecttofileafederalincometaxreturn,
individual. Or, you can request and participate in your appeal on
won't claim dependents on that return, and can't be claimed as a
your own.
dependent on anyone else's federal income tax return.
* If you request an appeal, you may be able to keep your eligibility
* IconfirmthatI'mnotofferedhealthcoveragefromanemployer.
for coverage while your appeal is pending.
We need this information to check your eligibility for help paying for
* The outcome of an appeal could change the eligibility of other
health coverage if you choose to apply. We'll check your answers
members of your household.
using information in our electronic databases and databases from
To appeal your Marketplace eligibility results, log into your Marketplace
theInternalRevenueService(IRS),SocialSecurity,theDepartment
account at www.HealthCare.gov/marketplace/individual or call
of Homeland Security, and/or a consumer reporting agency. If the
1-800-318-2596. TTY users should call 1-855-889-4325. You can
information doesn't match, we may ask you to send us proof.
also mail an appeal request form or your own letter requesting an
Renewal of coverage in future years
appeal to Health Insurance Marketplace, Dept. of Health and
To make it easier to determine my eligibility for help paying for health
Human Services, 465 Industrial Blvd., London, KY 40750-0001.
coverage in future years, I agree to allow the Marketplace to use
You can appeal eligibility for purchasing health coverage through the
income data, including information from tax returns. The Marketplace
Marketplace, enrollment periods, tax credits, cost-sharing reductions,
will send me a notice and let me make any changes, and I can opt out
Medicaid, and CHIP, if you were denied these. If you qualify for tax
at any time.
credits or cost-sharing reductions, you can appeal the amount we
determinedyouareeligiblefor.Dependingonyourstate,youmaybe
able to appeal through the Marketplace or you may have to request
an appeal with the state Medicaid or CHIP agency.
Sign this application. ThepersonwhofilledoutStep1shouldsignthisapplication.Ifyou'reanauthorizedrepresentative,youmaysignhereas
long as you've provided the information required in Appendix C.
Signature
Date(mm/dd/yyyy)
/
/
STEP 5 Mail completed application.
Mail your signed application to:
Health Insurance Marketplace
Dept. of Health and Human Services
465 Industrial Blvd.
London, KY 40750-0001
If you want to register to vote, you can complete a voter registration form at usa.gov.
NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-800-318-2596. Para obtener una copia de este formulario en
Espanol, llame 1-800-318-2596. If you need help in a language other than English, call 1-800-318-2596 and tell the customer service representative
the language you need. We'll get you help at no cost to you. TTY users should call 1-855-889-4325.

APPENDIX C
Form Approved
OMB No. 0938-1191
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.
Thispersoniscalledan"authorizedrepresentative."Ifyoueverneedtochangeyourauthorizedrepresentative,contactthe
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
6. ZIP code
7. Phone number
(
)
-
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 related to this application.
10. Your signature
11. Date (mm/dd/yyyy)
/
/
For certified application counselors, navigators, agents, and brokers only.
Completethissectionifyou'reacertifiedapplicationcounselor,navigator,agent,orbrokerfillingoutthisapplicationfor
somebody else.
1. Application start date (mm/dd/yyyy)
/
/
2. First name, Middle name, Last name, & Suffix
Joseph Micah Shope
3. Organization name
InsureAcare (FFM username)
4. ID number (if applicable)
5. Agents/Brokers only: NPN number
1 6 3 4 4 3 5 9
NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-800-318-2596. Para obtener una copia de este formulario en
Espanol, llame 1-800-318-2596. If you need help in a language other than English, call 1-800-318-2596 and tell the customer service representative
the language you need. We'll get you help at no cost to you. TTY users should call 1-855-889-4325.