Fillable Printable Health Insurance Form - California
Fillable Printable Health Insurance Form - California
Health Insurance Form - California
Application for
Health Insurance
TM
Covered California is the place where individuals and families can
get aordable health insurance. With just one application, you’ll nd out
if you qualify for free or low-cost health insurance, including Medi-Cal.
The state of California created Covered California™ to help you
and your family get health insurance.
Having health insurance can give you peace of mind and help make it
possible for you to stay healthy. With insurance, you’ll know you and your
family can get health care when you need it.
Use this application to see what insurance choices you qualify for:
Free or low-cost insurance from Medi-Cal
Low-cost insurance for pregnant women through Access for Infants
and Mothers (AIM)
Affordable private health insurance plans
Help paying for your health insurance
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.
You can use this application to apply for anyone in your family,
even if they already have insurance now.
Apply faster through Covered California
at CoveredCA.com
Or call: 1-800-300-1506 (TTY: 1-888-889-4500)
You can call Monday to Friday, 8 a.m. to 8 p.m.,
and Saturday, 8 a.m. to 6 p.m.
You can get this
application in
other languages
Español 1-800-300-0213
1-800-300-1533
Tiếng Việt 1-800-652-9528
1-800-738-9116
Tagalog 1-800-983-8816
Heccrbq 1-800-778-7695
1-800-996-1009
1-800-921-8879
1-800-906-8528
Hmoob 1-800-771-2156
1-800-826-6317
Call 1-800-300-1506 to
get this application in
other formats, such as
large print.
See Inside
Things to know 1
Application 2–19
Attachments A–F 20–28
Frequently Asked 29–33
Questions (FAQ)
Your destination for affordable
health insurance, including Medi-Cal
STATE OF CALIFORNIA Health Insurance Application
(11/13)
|
CCFRM604
CCFRM604 (11/13) EN
Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). The call is free. You can call
Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.
Need help?
1
Things to know
What you need
to know when
you apply
Social Security numbers for applicants who are U.S. citizens, or document
information
for immigrants with satisfactory status who need insurance. Proof of citizenship or
immigration status is required only for applicants.
Employer and income information for everyone in your family.
Your federal tax information. For example, the person who files taxes as head of
household and the dependents claimed on your taxes.
Information about health insurance that you or any family member
gets through a job.
We ask about income and other information to make sure you and your family
get the most benefits possible.
We keep your information private and secure, as required by law.
We’ll use your information only to see if you qualify for health insurance.
Families that include immigrants can apply. You can apply for your child even if you
aren’t eligible for coverage. Applying for your eligible child won’t affect your immigration
status or chances of becoming a permanent resident or citizen.
If you don’t file taxes, you can still qualify for free or low-cost insurance through Medi-Cal.
If you are a federally recognized American Indian or Alaska Native who is getting
services from the Indian Health Services, tribal health programs, or urban Indian health
programs, you may still qualify for health insurance through Covered California.
Apply faster
online
Apply online at
CoveredCA.com. It's safe, secure, and fast
–
and you will get
results sooner!
When you’re
done
Send your completed and signed application to:
Covered California
P.O. Box 989725
West Sacramento, CA 95798-9725
If you don’t have all the information we ask for, sign and send in your application
anyway.
We can call you to help you finish your application.
Do not send your health insurance plan enrollment payment with this application.
Your plan will send you an invoice for the amount you owe.
Get help
with this
application
We're here to help you! You can get help at no cost.
Online: CoveredCA.com
Phone: Call our Customer Service Center at 1-800-300-1506 (TTY: 1-888-889-4500).
The call is free. You can call Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m.
In person: We have trained Certified Enrollment Counselors and Certified Insurance
Agents who can help you. For a list of Certified Enrollment Counselors and Certified
Insurance Agents near where you live or work, or a list of county social services offices
near you, visit CoveredCA.com or call 1-800-300-1506 (TTY: 1-888-889-4500).
This help is free!
If you have a disability or other need, we can provide assistance with completing this
application at no cost to you. You can go to your local county social services office in
person or call our Customer Service Center at 1-800-300-1506 (TTY: 1-888-889-4500).
CCFRM604 (11/13) EN
2
¿Preguntas?
Llame a Covered California al 1-800-300-1506 (TTY: 1-888-889-4500). La llamada es gratuita.
Usted puede llamar de lunes a viernes de 8 a.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m.
O visite CoveredCA.com.
Step 1:
Tell us about the adult who will be our main contact
for this application
First name Middle name Last name Suffix (examples: Sr., Jr., III, IV)
Home address Apartment #
City (home address)
State ZIP code County
Check here if you do not have a home address. You must give us a mailing address below.
Check here if your mailing address is the same as your home address.
If it is not the same, you must give us your mailing address below:
Mailing address or P.O. box
(if dierent from home address)
Apartment #
City (mailing address)
State ZIP code County
Best phone number to reach you
Home
Cell
Work
Number: ( ) –
Other phone number
Home
Cell
Work
Number: ( ) –
What language should we write to you in?
What language do you want us to speak to you in?
How would you like to get information about this application?
Phone
Mail
Email
Email address: ____________________________________________________________________________________________________________________________________
Are you applying for a child less than 1 year old?
Infants less than one year old are eligible for Medi-Cal if their mother was on Medi-Cal or AIM at the
time of delivery. You do not need to fill out an application to get Medi-Cal for an infant born to a
mother with Medi-Cal or AIM at the time of delivery. Call your county social services office when your
baby is born to make sure your baby is covered. Or fill out the information below.
Optional: If the following information is provided, the infant may be automatically eligible for Medi-Cal.
You do not have to fill out Step 2 of this application for the infant.
Are you applying for a child less than 1 year old?
Yes
No
If yes, did the child’s mother have Medi-Cal or AIM when the child was born?
Yes
No
If yes, will the child’s mother be listed on this application?
Yes
No
If yes, the mother is Person #_____________________ on this application
If no, what is the mother’s first and last name? ______________________________________________________________________
Please provide the mother’s Medi-Cal number, AIM number, or SSN __________________________________________________________
Start application here (use blue or black ink only)
CCFRM604 (11/13) EN
Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). The call is free. You can call
Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.
Need help?
3
Person 1 Tell us about yourself.
First name Middle name Last name Suffix (examples: Sr., Jr., III, IV) Relationship to you
Self
Are you:
Male
Female Are you:
Single
Never married
Married
Divorced
Registered domestic partner
Widowed
Date of birth (month / day / year)
Are you pregnant?
Yes
No If yes, how many babies are expected? ____________
What is the expected delivery date? ______________________________________________________________________________________
Applying for health insurance Even if you have insurance now, you might find better coverage or lower costs.
Are you applying for health insurance for yourself?
Yes If yes, answer the questions below and complete pages 4 and 5.
No If you are not applying for yourself but you are applying for a dependent, be sure to fill in page 5.
No If you are not applying for yourself or for a dependent, go to page 6.
Social Security number (SSN)
___
–
__
–
____
If you do not have an SSN, what is the reason?
Adoption Taxpayer Identification Number (ATIN)
________________________________________________________
Individual Taxpayer Identification Number (ITIN)
_________________________________________________________
Religious exemption
I do not qualify for an SSN
You must provide a Social Security number (SSN) if you wish to apply for health insurance. We use Social
Security numbers (SSNs) to check income and other information. Even if you are not applying, giving your SSN
will help us review your application faster. Be sure to provide your SSN if you are not applying for yourself but
you file taxes and are applying for someone in your tax household.
If someone who is applying does not have an SSN and would like help getting one, call 1-800-300-1506
(TTY: 1-888-889-4500 ) or visit CoveredCA.com.
Person 1 continued on next page
Step 2:
Tell us about yourself and your family
Your income and family size help us decide what programs you qualify for. With this information, we
can make sure everyone gets the best coverage possible.
You must include these people on this application:
Your spouse
Your children who live with you
All parents living in the home with their child
Anyone on your federal income tax return, if you file one. You don’t need to file taxes to apply for
health insurance.
If you are claimed as a dependent on someone else's tax return, you must include all members of
the tax filing household that claimed you and any family members living with you.
Anyone else who lives with you
–
for example, a boyfriend, girlfriend, or roommate
–
will need to file
his or her own application if they want health insurance.
Complete Step 2 for each person in your family. Start with yourself!
To apply for more than four people on this application, make a copy of pages 6–8 for each
additional person.
We’ll keep all your information private, as required by law. We’ll use personal information only to
see if you qualify for health insurance. You do not need to provide the immigration status or Social
Security number (SSN) for those in your family who are not applying for health insurance.
CCFRM604 (11/13) EN
4
¿Preguntas?
Llame a Covered California al 1-800-300-1506 (TTY: 1-888-889-4500). La llamada es gratuita.
Usted puede llamar de lunes a viernes de 8 a.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m.
O visite CoveredCA.com.
Step 2:
Person 1 (continued)
Do you have other health insurance or are you offered insurance through a job?
Yes
No
If yes, fill out Attachment B on pages 22 and 23.
Do you have a physical, mental, emotional, or developmental disability?
Yes
No See FAQ #27 for more information on what it means to have a disability.
Do you need help with long-term care or home
and community-based services?
Yes
No
Are you a U.S. citizen or U.S. national?
Yes
No
If you are not a U.S. citizen or U.S. national, answer these questions:
Do you have satisfactory immigration status?
Yes To see if you have satisfactory status, go to Attachment E on page 27 for a list.
Then write the document information here. In most cases your document ID number will be your Alien Registration Number.
Document type: _________________________________________ ID number: ___________________________________________________________________________
Country of issuance: __________________________________________________________________ Expiration date: ___________________________________________________________________
Name as it appears on the document: ______________________________________________________________________________________________________________________________________
Have you lived in the U.S. since 1996?
Yes
No
Are you, your spouse, or an unmarried dependent child an honorably discharged
veteran or active-duty member of the U.S. armed forces?
Yes
No
Do you receive Medicare benefits?
Yes
No
Did you have a medical expense in the last 3 months that you need help paying for?
Yes
No
Do you live with any children under the age of 19?
Yes
No
If yes, do you take care of the child or children?
Yes
No
Are you 18 to 20 years old and a full-time student?
Yes
No
Are you 18 to 26 years old?
Yes
No
If yes,
were you in foster care in any state on your 18th birthday?
Yes
No
Are you 18 years old or younger?
Yes
No
How many parents live with you? ______________
Are you temporarily living out of state?
Yes
No
If you would like to choose a health insurance plan now, check here
and fill out Attachment D on page 25.
Tell us about your race
This information is confidential and will only be used to make sure that everyone has the
same access to health care. It will not be used to decide what health insurance you qualify for.
What is your race?
(optional;
check all that apply)
Are you of Hispanic, Latino, or Spanish
origin?
(
optional)
Yes
No
If yes, check which ones:
Mexican, Mexican American, Chicano
Salvadoran
Guatemalan
Cuban
Puerto Rican
Other Hispanic, Latino, or Spanish
origin: ______________________________
White
Black or African
American
American Indian
or Alaska Native
Asian Indian
Cambodian
Chinese
Filipino
Hmong
Japanese
Korean
Laotian
Vietnamese
Native Hawaiian
Guamanian or
Chamorro
Samoan
Other
__________________________________
Check here if you are an American Indian or Alaska Native, and fill out Attachment A on pages 20 and 21.
Person 1 continued on next page
Federal income tax information If you don’t file taxes, you can still qualify for free or low-cost insurance through
Medi-Cal. We will keep your information private. We will use your information only to decide if you qualify for health insurance.
Are you the primary tax filer (your name was first on the tax return)?
Yes
No
Only one person on this application can be the primary tax filer.
Are you going to file taxes for the benefit year?
Yes
No
If yes, how will you file?
Head of household
Single
Married filing jointly
Married filing separately
Does anyone claim you as a dependent on their taxes?
Yes
No
If yes, who?
Person # ______________________
on this application
This person is a parent without custody
This person is a parent without custody who is not listed on this application
CCFRM604 (11/13) EN
Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). The call is free. You can call
Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.
Need help?
5
Step 2:
Person 1 (continued)
Tell us about your current job and how you get money Attach an extra page if you need more space.
Do you work now?
Yes If yes, answer the questions below.
No If no, go to other income on this page.
Where do you work now? If you have more jobs, attach another sheet of paper.
JOB 1:
How do you get paid?
Hourly: How many hours per week? __________
Daily: How many days per week? ___________
Weekly
Every two weeks
Twice a month
Monthly
Quarterly
Every six months
Yearly
One-time payment (See FAQ #33 on page 33.)
Employer name (optional)
How much do you get paid (before taxes)? $ __________________________________
JOB 2:
How do you get paid?
Hourly: How many hours per week? __________
Daily: How many days per week? ___________
Weekly
Every two weeks
Twice a month
Monthly
Quarterly
Every six months
Yearly
One-time payment (See FAQ #33 on page 33.)
Employer name (optional)
How much do you get paid (before taxes)? $ __________________________________
Are you self-employed?
JOB 1:
Are you self-employed?
Yes If yes, answer the questions below.
No If no, go to other income on this page.
Type of work
How much net income will you get from self-employment this month? $ _______________________________________________________________
Net income means the profits left over after expenses are paid. Attachment E on page 27 lists what could be counted.
JOB 2:
Are you self-employed?
Yes If yes, answer the questions below.
No If no, go to other income on this page.
Type of work
How much net income will you get from self-employment this month? $ _______________________________________________________________
Net income means the profits left over after expenses are paid. Attachment E on page 27 lists what could be counted.
Do you have other income? Other income is money you get from something other than your job. Do not include child support
payments, veteran’s payments, or Supplemental Security Income (SSI). Go to Attachment E on page 27 to see examples of other income.
Do you have other income?
Yes If yes, answer the questions below.
No If no, go to income change on this page.
Where does this
income come from?
How often do you get paid? (check one) How much?
Hourly: How many hours per week? __________
Daily: How many days per week? ___________
Weekly
Every two weeks
Twice a month
Monthly
Quarterly
Every six months
Yearly
One-time payment (See FAQ #33 on page 33.)
$
Hourly: How many hours per week? __________
Daily: How many days per week? ___________
Weekly
Every two weeks
Twice a month
Monthly
Quarterly
Every six months
Yearly
One-time payment (See FAQ #33 on page 33.)
$
Does your income change from month to month? If it does, answer the two questions below.
What do you expect your total income to be this year?
(optional) $ _____________________________________________
If you expect your income to change next year, what will the
new total income be? (optional) $ ___________________________________________
Do you have deductions? If you pay for certain things that can be deducted on a federal income tax return, telling us about them
may lower the cost of health insurance. Do not include self-employment expenses. Attachment E on page 27 lists other types of deductions.
Do you have deductions?
Yes If yes, answer the questions below.
No If no, go to the next page.
Type of deduction How often do you get or pay for this deduction? (check one) How much?
Alimony paid
Student loan interest
Other
Hourly: How many hours per week? __________
Daily: How many days per week? ___________
Weekly
Every two weeks
Twice a month
Monthly
Quarterly
Every six months
Yearly
One-time payment (See FAQ #33 on page 33.)
$
Alimony paid
Student loan interest
Other
Hourly: How many hours per week? __________
Daily: How many days per week? ___________
Weekly
Every two weeks
Twice a month
Monthly
Quarterly
Every six months
Yearly
One-time payment (See FAQ #33 on page 33.)
$
CCFRM604 (11/13) EN
6
¿Preguntas?
Llame a Covered California al 1-800-300-1506 (TTY: 1-888-889-4500). La llamada es gratuita.
Usted puede llamar de lunes a viernes de 8 a.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m.
O visite CoveredCA.com.
Step 2:
Person 2 Tell us about the next person living in your home.
If you have more than four people on this application, make a copy of pages 6–8 for
each additional person.
First name Middle name Last name Suffix (examples: Sr., Jr., III, IV) Relationship to you
Check here if this person's home address is the same as the main contact's home address.
If it is not the same, you must give us this person's home address below:
Home address Apartment #
City (home address)
State ZIP code County
Check here if this person does not have a home address. You must give us a mailing address below.
Check here if this person's mailing address is the same as the main contact's mailing address.
If it is not the same, you must give us this person's mailing address below:
Mailing address or P.O. box
(if dierent from home address)
Apartment #
City (mailing address)
State ZIP code County
Best phone number to reach this person
Home
Cell
Work
Number: ( )
–
Other phone number
Home
Cell
Work
Number: ( )
–
Email address:
What language should we write to this person in?
What language does this person want us to speak to him or her in?
Is this person:
Male
Female Is this person:
Single
Never married
Married
Divorced
Registered domestic partner
Widowed
Date of birth (month / day / year)
Is this person pregnant?
Yes
No If yes, how many babies are expected? _____________
What is the expected delivery date? _________________________________________________________________________________________
Applying for health insurance Even if this person has insurance now, you might find better coverage or lower costs.
Is this person applying for health insurance?
Yes If yes, answer the questions below.
No If no, SSN information is optional.
Social Security number (SSN)
___
–
__
–
____
If this person does not have an SSN, what is the reason?
Adoption Taxpayer Identification Number (ATIN)
________________________________________________________
Individual Taxpayer Identification Number (ITIN)
_________________________________________________________
Religious exemption
Does not qualify for an SSN
Federal income tax information If this person didn’t file taxes, he or she can still qualify for free or low-cost insurance
through Medi-Cal. We will keep the information private and use it only to decide if the person qualifies for health insurance.
Is this person the primary tax filer (his or her name was first on the tax return)?
Yes
No
Only one person on this application can be the primary tax filer.
Is this person going to file taxes for the benefit year?
Yes
No If yes, how will he or she file?
Head of household
Single
Dependent
Married filing jointly
Married filing separately
Does anyone claim this person as a dependent on their taxes?
Yes
No
If yes, who?
Person # ______________________
on this application
This person is a parent without custody
This person is a parent without custody who is not listed on this application
Person 2 continued on next page
CCFRM604 (11/13) EN
Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). The call is free. You can call
Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.
Need help?
7
Step 2:
Person 2 (continued)
Does this person have other health insurance or is this person offered insurance through a job?
Yes
No
If yes, fill out Attachment B on pages 22 and 23.
Does this person have a physical, mental, emotional, or
developmental disability?
Yes
No
See FAQ #27 for more information on what it means to have a disability.
Does this person need help with long-term care or
home and community-based services?
Yes
No
Is this person a U.S. citizen or U.S. national?
Yes
No
If this person is not a U.S. citizen or
U.S.
national, answer these questions:
Does this person have satisfactory immigration status?
Yes To see if this person has satisfactory status, go to Attachment E on page 27.
for a list. Then write the document information here. In most cases the document ID number will be the Alien Registration Number.
Document type: __________________________________________________________________________ ID number: __________________________________________________________________________
Country of issuance: ___________________________________________________________________ Expiration date: __________________________________________________________________
Name as it appears on the document: ______________________________________________________________________________________________________________________________________
Has this person lived in the U.S. since 1996?
Yes
No
Is this person, this person's spouse, or an unmarried dependent child an honorably discharged veteran
or active-duty member of the U.S. armed forces?
Yes
No
Does
this person
receive Medicare benefits?
Yes
No
Did
this person
have a medical expense in the last 3 months that he or she
needs help paying for?
Yes
No
Does this person live with any children under the age of 19?
Yes
No
If yes, does this person take care of the child or children?
Yes
No
Is this person 18 to 20 years old and a full-time student?
Yes
No
Is this person 18 to 26 years old?
Yes
No
If yes,
was this person in foster care in any state on his or her 18th birthday?
Yes
No
Is this person 18 years old or younger?
Yes
No
How many parents live with this person? _________________
Is this person temporarily living out of state?
Yes
No
Tell us about this person’s race
This information is confidential and will only be used to make sure that everyone
has the same access to health care. It will not be used to decide what health insurance you qualify for.
What is this person's race?
(optional; c
heck all that apply)
Is this person of Hispanic, Latino, or
Spanish origin?
(
optional)
Yes
No
If yes, check which ones:
Mexican, Mexican American, Chicano
Salvadoran
Guatemalan
Cuban
Puerto Rican
Other Hispanic, Latino, or Spanish
origin: ______________________________
White
Black or African
American
American Indian
or Alaska Native
Asian Indian
Cambodian
Chinese
Filipino
Hmong
Japanese
Korean
Laotian
Vietnamese
Native Hawaiian
Guamanian or
Chamorro
Samoan
Other
____________________________
Check here if this person is an American Indian or Alaska Native, and fill out Attachment A on pages 20 and 21.
Person 2 continued on next page
CCFRM604 (11/13) EN
8
¿Preguntas?
Llame a Covered California al 1-800-300-1506 (TTY: 1-888-889-4500). La llamada es gratuita.
Usted puede llamar de lunes a viernes de 8 a.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m.
O visite CoveredCA.com.
Step 2:
Person 2 (continued)
Tell us about this person's current job and how he or she gets money Attach an extra page if you need more space.
Does this person work now?
Yes If yes, answer the questions below.
No If no, go to other income on this page.
Where does this person work now? If he or she has more jobs, attach another sheet of paper.
JOB 1:
How does this
person get paid?
Hourly: How many hours per week? __________
Daily: How many days per week? ___________
Weekly
Every two weeks
Twice a month
Monthly
Quarterly
Every six months
Yearly
One-time payment (See FAQ #33 on page 33.)
Employer name (optional)
How much does this person get paid (before taxes)? $ __________________
JOB 2:
How does this
person get paid?
Hourly: How many hours per week? __________
Daily: How many days per week? ___________
Weekly
Every two weeks
Twice a month
Monthly
Quarterly
Every six months
Yearly
One-time payment (See FAQ #33 on page 33.)
Employer name (optional)
How much does this person get paid (before taxes)? $ __________________
Is this person self-employed?
JOB 1:
Is this person self-employed?
Yes If yes, answer the questions below.
No If no, go to other income on this page.
Type of work
How much net income will this person get from self-employment this month? $ ___________________________________________________
Net income means the profits left over after expenses are paid. Attachment E on page 27 lists what could be counted.
JOB 2:
Is this person self-employed?
Yes If yes, answer the questions below.
No If no, go to other income on this page.
Type of work
How much net income will this person get from self-employment this month? $ ___________________________________________________
Net income means the profits left over after expenses are paid. Attachment E on page 27 lists what could be counted.
Does this person have other income? Other income is money you get from something other than your job. Go to Attachment E on
page 27 to see examples of other income. Do not include child support payments, veteran’s payments, or Supplemental Security Income (SSI).
Does this person have other income?
Yes If yes, answer the questions below.
No If no, go to income change on this page.
Where does this
income come from?
How often does this person get paid? (check one) How much?
Hourly: How many hours per week? __________
Daily: How many days per week? ___________
Weekly
Every two weeks
Twice a month
Monthly
Quarterly
Every six months
Yearly
One-time payment (See FAQ #33 on page 33.)
$
Hourly: How many hours per week? __________
Daily: How many days per week? ___________
Weekly
Every two weeks
Twice a month
Monthly
Quarterly
Every six months
Yearly
One-time payment (See FAQ #33 on page 33.)
$
Does this person's income change from month to month? If it does, answer the two questions below.
What does this person expect this person's total income to be
this year? (optional) $ ____________________________________
If you expect this person's income to change next year, what
will the new total income be? (optional) $ ______________________________
Does this person have deductions? If this person pays for certain things that can be deducted on a federal income tax return, telling us
about them may lower the cost of health insurance. Do not include self-employment expenses. Attachment E on page 27 lists other types of deductions.
Does this person have deductions?
Yes If yes, answer the questions below.
No If no, go to the next page.
Type of deduction How often does this person get or pay for this deduction? (check one) How much?
Alimony paid
Student loan interest
Other
Hourly: How many hours per week? __________
Daily: How many days per week? ___________
Weekly
Every two weeks
Twice a month
Monthly
Quarterly
Every six months
Yearly
One-time payment (See FAQ #33 on page 33.)
$
Alimony paid
Student loan interest
Other
Hourly: How many hours per week? __________
Daily: How many days per week? ___________
Weekly
Every two weeks
Twice a month
Monthly
Quarterly
Every six months
Yearly
One-time payment (See FAQ #33 on page 33.)
$
CCFRM604 (11/13) EN
Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). The call is free. You can call
Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.
Need help?
9
Step 2:
Person 3 Tell us about the next person living in your home.
First name Middle name Last name Suffix (examples: Sr., Jr., III, IV) Relationship to you
Check here if this person's home address is the same as the main contact's home address.
If it is not the same, you must give us this person's home address below:
Home address Apartment #
City (home address)
State ZIP code County
Check here if this person does not have a home address. You must give us a mailing address below.
Check here if this person's mailing address is the same as the main contact's mailing address.
If it is not the same, you must give us this person's mailing address below:
Mailing address or P.O. box
(if dierent from home address)
Apartment #
City (mailing address)
State ZIP code County
Best phone number to reach this person
Home
Cell
Work
Number: ( )
–
Other phone number
Home
Cell
Work
Number: ( )
–
Email address:
What language should we write to this person in?
What language does this person want us to speak to him or her in?
Is this person:
Male
Female Is this person:
Single
Never married
Married
Divorced
Registered domestic partner
Widowed
Date of birth (month / day / year)
Is this person pregnant?
Yes
No If yes, how many babies are expected? _____________
What is the expected delivery date? _________________________________________________________________________________________
Applying for health insurance Even if this person has insurance now, you might find better coverage or lower costs.
Is this person applying for health insurance?
Yes If yes, answer the questions below.
No If no, SSN information is optional.
Social Security number (SSN)
___
–
__
–
____
If this person does not have an SSN, what is the reason?
Adoption Taxpayer Identification Number (ATIN)
________________________________________________________
Individual Taxpayer Identification Number (ITIN)
_________________________________________________________
Religious exemption
Does not qualify for an SSN
Federal income tax information If this person didn’t file taxes, he or she can still qualify for free or low-cost insurance
through Medi-Cal. We will keep the information private and use it only to decide if the person qualifies for health insurance.
Is this person the primary tax filer (his or her name was first on the tax return)?
Yes
No
Only one person on this application can be the primary tax filer.
Is this person going to file taxes for the benefit year?
Yes
No If yes, how will he or she file?
Head of household
Single
Dependent
Married filing jointly
Married filing separately
Does anyone claim this person as a dependent on their taxes?
Yes
No
If yes, who?
Person # ______________________
on this application
This person is a parent without custody
This person is a parent without custody who is not listed on this application
Person 3 continued on next page
CCFRM604 (11/13) EN
10
¿Preguntas?
Llame a Covered California al 1-800-300-1506 (TTY: 1-888-889-4500). La llamada es gratuita.
Usted puede llamar de lunes a viernes de 8 a.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m.
O visite CoveredCA.com.
Step 2:
Person 3 (continued)
Does this person have other health insurance or is this person offered insurance through a job?
Yes
No
If yes, fill out Attachment B on pages 22 and 23.
Does this person have a physical, mental, emotional, or
developmental disability?
Yes
No
See FAQ #27 for more information on what it means to have a disability.
Does this person need help with long-term care or
home and community-based services?
Yes
No
Is this person a U.S. citizen or U.S. national?
Yes
No
If this person is not a U.S. citizen or
U.S.
national, answer these questions:
Does this person have satisfactory immigration status?
Yes To see if this person has satisfactory status, go to Attachment E on page 27.
for a list. Then write the document information here. In most cases the document ID number will be the Alien Registration Number.
Document type: __________________________________________________________________________ ID number: __________________________________________________________________________
Country of issuance: ___________________________________________________________________ Expiration date: __________________________________________________________________
Name as it appears on the document: ______________________________________________________________________________________________________________________________________
Has this person lived in the U.S. since 1996?
Yes
No
Is this person, this person's spouse, or an unmarried dependent child an honorably discharged veteran
or active-duty member of the U.S. armed forces?
Yes
No
Does
this person
receive Medicare benefits?
Yes
No
Did
this person
have a medical expense in the last 3 months that he or she
needs help paying for?
Yes
No
Does this person live with any children under the age of 19?
Yes
No
If yes, does this person take care of the child or children?
Yes
No
Is this person 18 to 20 years old and a full-time student?
Yes
No
Is this person 18 to 26 years old?
Yes
No
If yes,
was this person in foster care in any state on his or her 18th birthday?
Yes
No
Is this person 18 years old or younger?
Yes
No
How many parents live with this person? _________________
Is this person temporarily living out of state?
Yes
No
Tell us about this person’s race
This information is confidential and will only be used to make sure that everyone
has the same access to health care. It will not be used to decide what health insurance you qualify for.
What is this person's race?
(optional; c
heck all that apply)
Is this person of Hispanic, Latino, or
Spanish origin?
(
optional)
Yes
No
If yes, check which ones:
Mexican, Mexican American, Chicano
Salvadoran
Guatemalan
Cuban
Puerto Rican
Other Hispanic, Latino, or Spanish
origin: ______________________________
White
Black or African
American
American Indian
or Alaska Native
Asian Indian
Cambodian
Chinese
Filipino
Hmong
Japanese
Korean
Laotian
Vietnamese
Native Hawaiian
Guamanian or
Chamorro
Samoan
Other
____________________________
Check here if this person is an American Indian or Alaska Native, and fill out Attachment A on pages 20 and 21.
Person 3 continued on next page
