Application for Health Coverage ; Help Paying Costs (Short Form)

Use this application to see what coverage you qualify for Affordable private health insurance plans that offer comprehensive coverage to help you stay well A new tax credit that can immediately help pay your premiums for health coverage Free or low-cost insurance from Medicaid or the Children’s health insurance Program (ChiP) Who can use this application? single adults who: • � Aren’t offered health coverage from their employer Don’t have any dependents and can’t be claimed as a dependent on someone else’s tax return NOTE: if any of the following apply, you need to fill out a different form to make sure you get the most benefits possible: • � 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.

Application for Health Coverage & Help Paying Costs (Short Form)

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