Fillable Application for Health and Dental Insurance Coverage (Massachusetts)

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Application for Health and Dental Insurance Coverage (Massachusetts)

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The Application for Health and Dental Insurance Coverage (Massachusetts) form is 8 pages long and contains:

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  • 20 check-boxes
  • 225 other fields

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11/14
Application for
Health and Dental
Insurance Coverage
Who can use this
application?
Use this application for yourself and anyone in your household who
needs health or dental insurance coverage. People in your household could
include a spouse, a child under the age of 27, or a child over the age of 26
if they have a disability.
Apply faster online.
Apply faster online at MAhealthconnector.org.
Get help with
this application:
Visit MAhealthconnector.org.
Call our Customer Service at 1-877 MA ENROLL (1-877-623-6765) or
TTY: 1-877-623-7773.
In person: there may be counselors in your area who can help.
Visit MAhealthconnector.org for more information.
En Español: Llame a nuestro centro de ayuda gratis al
1-877 MA ENROLL (1-877-623-6765).
If you need help in a language other than English, call 1-877 MA ENROLL
(1-877-623-6765) and tell the Customer Service Representative the
language you need. We’ll get you help at no cost to you.
If someone is helping you ll out this application, you may need
to complete Appendix A.
Sending the application:
Send your complete, signed application to:
Massachusetts Health Connector
133 Portland Street, 1st Floor
Boston, MA 02114-1707
or fax to 617-887-8745.
Filling out this application doesn’t mean you have to buy health coverage.
Get help paying
for insurance:
You need to use a different application to get help with costs.
You could qualify for:
A new tax credit that can help pay your premiums for health
insurance coverage.
Free or low-cost health insurance plan from MassHealth. You may qualify
for a free or low-cost program even if you earn as much as $95,400 a
year (for a family of 4). Visit MAhealthconnector.org to learn more.
If you’re not sure what you qualify for, go to MAhealthconnector.org
and apply online.
Visit MAhealthconnector.org or call 1-877 MA ENROLL (1-877-623-6765)
or
TTY: 1-877-623-7773, Monday to Friday, 8:00 a.m. to 6:00 p.m.
Questions?
1 of 8
Visit MAhealthconnector.org or call 1-877 MA ENROLL (1-877-623-6765)
or
TTY: 1-877-623-7773, Monday to Friday, 8:00 a.m. to 6:00 p.m.
Questions?
2 of 8
11/14
PERSON 1
Please be sure to answer all questions and ll out all parts of this application.
First name Middle name Last name Sufx
Home
address (Not PO box) Check here
if you are homeless.
Unit or apartment number
City State ZIP code County
Mailing
address Check here
if same as home address.
Unit or apartment number
City State ZIP code County
Best phone number
Home
Work
Cell Other phone number
Home
Work
Cell
Email address:
Do you want to get information about this application by email?
Yes
No
Language you prefer to speak
(if not English) Language you prefer to write (if not English)
Do you need health coverage?
Yes
No
Do you need dental coverage?
Yes
No
If yes, have you had dental insurance within the last 12 months?
Yes
No
If you need health or dental coverage, answer all the questions below. If not, go to Step 2 on page 3.
Social Security number (SSN): ___ ___ ___ /___ ___ /___ ___ ___ ___
If you do not have a Social Security number, please choose one of the
following reasons:
Illness exception
Non-citizen exception

Just applied
Religious exception
We need Social Security numbers (SSNs)
for anyone who wants coverage. We use
SSNs to verify citizenship. If someone
doesn’t have an SSN, visit socialsecurity.gov
or call 1-800-772-1213.
Are you
Male
Female
Date of birth
(month/day/year)
Are you a U.S. citizen or U.S. national?
Yes
No
If yes, are you a naturalized citizen?
Yes
No Naturalization or citizenship number _______________
If you are not a U.S. citizen or U.S. national, do you have an eligible immigration status?
For more information on acceptable immigration documents, go to MAhealthconnector.org.
Yes. If yes, fill in the information about your status and documents below:
Immigration status
____________________________________ Immigration document type __________________
Document, passport, or card number _____________________ Passport or document expiration date _________
Alien number ________________________________________ Status award date _________________________
Have you lived in the U.S. since August 22, 1996?
Yes
No
Are you, or your spouse or parent a veteran or an active-duty member of the U.S. military?
Yes
No
Are you a resident of Massachusetts?
Yes
No
If yes, do you intend to stay in Massachusetts, even if you don’t have a xed address?
Yes
No
If no, are you temporarily living outside Massachusetts?
Yes
No
STEP 1
Tell us about yourself.
Choose one adult in the family to be the contact person for your application.
Visit MAhealthconnector.org or call 1-877 MA ENROLL (1-877-623-6765)
or
TTY: 1-877-623-7773, Monday to Friday, 8:00 a.m. to 6:00 p.m.
Questions?
3 of 8
11/14
PERSON 2
First name Middle name Last name Sufx Relationship to Person 1
Social Security number (SSN) Date of birth
(month/day/year) Is Person 2
Male?
Female?
Does Person 2 have the same home and mailing address as Person 1?
Yes
No If no, list address:
Home
address (Not PO box) Check here
if Person 2 is homeless.
Unit or apartment number
City State ZIP code County
Mailing address Check here
if same as home address.
Unit or apartment number
City State ZIP code County
Does Person 2 need health coverage?
Yes
No
Does Person 2 need dental coverage?
Yes
No
If yes, has Person 2 had dental insurance within the last 12 months?
Yes
No
If Person 2 needs health or dental coverage, answer all the questions below. If not, go to Person 3 or Step 3.
Is Person 2 a U.S. citizen or U.S. national?
Yes
No
If yes, is Person 2 a naturalized citizen?
Yes
No Naturalization or citizenship number _____________
If Person 2 is not a U.S. citizen or U.S. national, do they have an eligible immigration status?
For more information on acceptable immigration documents, go to MAhealthconnector.org.
Yes. If yes, fill in the information about their status and documents below:
Immigration status
____________________________________ Immigration document type __________________
Document, passport, or card number _____________________ Passport or document expiration date _________
Alien number ________________________________________ Status award date _________________________
Has Person 2 lived in the U.S. since August 22, 1996?
Yes
No
Is Person 2, or their spouse or parent a veteran or an active-duty member of the U.S. military?
Yes
No
Is Person 2 a resident of Massachusetts?
Yes
No
If yes, do they intend to stay in Massachusetts, even if you don’t have a xed address?
Yes
No
If no, are they temporarily living outside Massachusetts?
Yes
No
STEP 2
Tell us about anyone else who needs health or dental insurance coverage.
If you have more than 4 people to include, make a copy of this page.
Visit MAhealthconnector.org or call 1-877 MA ENROLL (1-877-623-6765)
or
TTY: 1-877-623-7773, Monday to Friday, 8:00 a.m. to 6:00 p.m.
Questions?
4 of 8
11/14
STEP 2
Tell us about anyone else who needs health or dental insurance coverage.
(continued)
PERSON 3
First name Middle name Last name Sufx Relationship to Person 1
Social Security number (SSN) Date of birth
(month/day/year) Is Person 3
Male?
Female?
Does Person 3 have the same home and mailing address as Person 1?
Yes
No If no, list address:
Home
address (Not PO box) Check here
if Person 3 is homeless.
Unit or apartment number
City State ZIP code County
Mailing address Check here
if same as home address.
Unit or apartment number
City State ZIP code County
Does Person 3 need health coverage?
Yes
No
Does Person 3 need dental coverage?
Yes
No
If yes, has Person 3 had dental insurance within the last 12 months?
Yes
No
If Person 3 needs health or dental coverage, answer all the questions below. If not, go to Person 4 or Step 3.
Is Person 3 a U.S. citizen or U.S. national?
Yes
No
If yes, is Person 3 a naturalized citizen?
Yes
No Naturalization or citizenship number _____________
If Person 3 is not a U.S. citizen or U.S. national, do they have an eligible immigration status?
For more information on acceptable immigration documents, go to MAhealthconnector.org.
Yes. If yes, fill in the information about their status and documents below:
Immigration status
____________________________________ Immigration document type __________________
Document, passport, or card number _____________________ Passport or document expiration date _________
Alien number ________________________________________ Status award date _________________________
Has Person 3 lived in the U.S. since August 22, 1996?
Yes
No
Is Person 3, or their spouse or parent a veteran or an active-duty member of the U.S. military?
Yes
No
Is Person 3 a resident of Massachusetts?
Yes
No
If yes, do they intend to stay in Massachusetts, even if you don’t have a xed address?
Yes
No
If no, are they temporarily living outside Massachusetts?
Yes
No
Visit MAhealthconnector.org or call 1-877 MA ENROLL (1-877-623-6765)
or
TTY: 1-877-623-7773, Monday to Friday, 8:00 a.m. to 6:00 p.m.
Questions?
5 of 8
11/14
STEP 2
Tell us about anyone else who needs health or dental insurance coverage.
(continued)
PERSON 4
First name Middle name Last name Sufx Relationship to Person 1
Social Security number (SSN) Date of birth
(month/day/year) Is Person 4
Male?
Female?
Does Person 4 have the same home and mailing address as Person 1?
Yes
No If no, list address:
Home
address (Not PO box) Check here
if Person 4 is homeless.
Unit or apartment number
City State ZIP code County
Mailing address Check here
if same as home address.
Unit or apartment number
City State ZIP code County
Does Person 4 need health coverage?
Yes
No
Does Person 4 need dental coverage?
Yes
No
If yes, has Person 4 had dental insurance within the last 12 months?
Yes
No
If Person 4 needs health or dental coverage, answer all the questions below. If not, go to Step 3.
Is Person 4 a U.S. citizen or U.S. national?
Yes
No
If yes, is Person 4 a naturalized citizen?
Yes
No Naturalization or citizenship number _____________
If Person 4 is not a U.S. citizen or U.S. national, do they have an eligible immigration status?
For more information on acceptable immigration documents, go to MAhealthconnector.org.
Yes. If yes, fill in the information about their status and documents below:
Immigration status
____________________________________ Immigration document type __________________
Document, passport, or card number _____________________ Passport or document expiration date _________
Alien number ________________________________________ Status award date _________________________
Has Person 4 lived in the U.S. since August 22, 1996?
Yes
No
Is Person 4, or their spouse or parent a veteran or an active-duty member of the U.S. military?
Yes
No
Is Person 4 a resident of Massachusetts?
Yes
No
If yes, do they intend to stay in Massachusetts, even if you don’t have a xed address?
Yes
No
If no, are they temporarily living outside Massachusetts?
Yes
No
Visit MAhealthconnector.org or call 1-877 MA ENROLL (1-877-623-6765)
or
TTY: 1-877-623-7773, Monday to Friday, 8:00 a.m. to 6:00 p.m.
Questions?
6 of 8
11/14
STEP 3
American Indian or Alaska Native (AI/AN) family members
Are you or is anyone in your family an American Indian or Alaska Native?
Yes If yes, continue. If you have more people to include, make a copy of this page and attach.
No If no, go to Step 4.
AI/AN Person 1
First name Middle name Last name Sufx
Member of a federally recognized tribe?
Yes
No
If yes, tribe name and state afliation
AI/AN Person 2
First name Middle name Last name Sufx
Member of a federally recognized tribe?
Yes
No
If yes, tribe name and state afliation
STEP 4
Tell us about your tax household
Do you plan to le a federal income tax return next year?
No If no, go to Step 5.
Yes If yes, list all family members who will be included in your tax return, as well as their
tax relationship to you. If you have more people to include, make a copy of this page and attach.
Choose from the following tax relationship terms:
(Tax ler) Head of Household or Qualied Widow(er)
(Tax ler) Married, ling jointly
(Tax ler) Married, ling separately
Tax Dependent
Tax household Person 1
First name Middle name Last name Sufx
Tax relationship:
Tax household Person 2
First name Middle name Last name Sufx
Tax relationship:
Visit MAhealthconnector.org or call 1-877 MA ENROLL (1-877-623-6765)
or
TTY: 1-877-623-7773, Monday to Friday, 8:00 a.m. to 6:00 p.m.
Questions?
7 of 8
11/14
STEP 4
Tell us about your tax household (continued)
Tax household Person 3
First name Middle name Last name Sufx
Tax relationship:
Tax household Person 4
First name Middle name Last name Sufx
Tax relationship:
STEP 5
Read and sign this application.
Rights and Responsibilities
This application will be used to determine eligibility for unsubsidized health care administered through
the Commonwealth of Massachusetts.
1. The Massachusetts Health Connector may get any records or data to prove any information given on
this application and any supplements, or other information you give once you are a member and to
support continued eligibility.
2. The Massachusetts Health Connector may get records or data from federal and state data sources
and programs, such as the Social Security Administration, the Department of Homeland Security, and
the Registry of Motor Vehicles, to prove any information given on this application, or other information
once an individual becomes a member, and to support continued eligibility. We will keep all records
and data provided to us private, and only use and disclose it in accordance with applicable law.
3. You have consent and authorization from all individuals listed on the application or, if applicable,
their parent, guardian, or legally authorized representative, and, as allowed by any legal documents
you have submitted with this application, to act on their behalf to complete this application and any
ongoing or subsequent eligibility process and activity.
4. You understand your rights and responsibilities and the rights and responsibilities of all persons for
whom you are submitting this application, as explained on this signature page.
5. You have or will tell such persons about such rights and responsibilities and the other individuals for
whom you are signing also understand their rights and responsibilities.
6. You understand and agree that the Health Connector will treat electronic signatures and faxed
signature(s) or copies of signatures with the same force and effect as an original signature(s).
7. The information you have supplied is correct and complete to the best of your knowledge about
yourself and other members of your household.
8. You may be subject to penalties under federal law if you intentionally provide false or untrue information.
9. You
conrm that no one applying for health insurance on this application is incarcerated (detained or jailed).
If someone in this household is in jail, write their name and check one of the following options:
_________________________________________________________________________________ is in jail.
Is this person awaiting trial?
Yes
No
Visit MAhealthconnector.org or call 1-877 MA ENROLL (1-877-623-6765)
or
TTY: 1-877-623-7773, Monday to Friday, 8:00 a.m. to 6:00 p.m.
Questions?
8 of 8
11/14
Sign this application.
By signing below, you hereby certify under the pains and penalties of perjury that the submissions you
have made in this Application are true and complete to the best of your knowledge and you agree to
accept and comply with the Rights and Responsibilities above.
The person who lled out Step 1 should sign this application. If you’re an Authorized Representative,
you may sign here as long as you have completed a separate Authorized Representative Designation
(ARD) form.
Signature Date
(month/day/year)
STEP 5
Read and sign this application (continued)
STEP 6
Mail completed application.
Mail your signed application to:
Massachusetts Health Connector
133 Portland Street, 1st Floor
Boston, MA 02114-1707
FAX: 617-887-8745
Appendix A
Get help 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. This person is called an “Authorized Representative.” If you would
like to have an authorized representative, download the Authorized Representative Designation (ARD) Form
from our website at MAhealthconnector.org or call Customer Service at 1-877-MA ENROLL.
For enrollment assisters only
Complete this section if you are an enrollment assister and lling out this application for someone else.
Navigators must ll out a Navigator Designation Form if you have not done so already. Certied Application
Counselors must ll out a Certied Application Counselor Designation Form if you have not already done so.
Date (month/day/year)
Check one:
Navigator
Certied Application Counselor
First name Middle name Last name Sufx
Organization name
Organization identication number
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Application for Health and Dental Insurance Coverage (Massachusetts)

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Completed 19 August 2020

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