Health Care Form English

Health Care Form English

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Health Care Form English
    • Step 1: Personal Information  
    • Who do you need to include on this application? Tell us about all the family members who live with you. If you file taxes, we need to know about everyone on your tax return. DO Include: • Yourself • Your spouse • Your children under 21 who live with you • Your unmarried partner who needs health coverage • Anyone you include on your tax return, even if they • Anyone else under 21 who you take care of and lives with you.

      You DON’T have to include: • Your unmarried partner who doesn’t need health coverage • Your unmarried partner’s children • Your parents who live with you, but file their own tax return (if you’re over 21) • Other adult relatives who file their own tax return don’t live with you.

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    • Step 2: Dependents that you claim on your taxes or/and live in your household  
    • List the dependence you list on your taxes. Also include the children under 19 that live with you that you provide for their care.
    • Step 3: Current Job & Income Information  
    • Include All Your Household Income

      Your Income
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    • Spouse Income
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    • Other family Income
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    • Step 4: Authorization  
    • I’m signing this application under penalty of perjury, which means I’ve provided true answers to all the questions on this form to the best of my knowledge. I know that I may be subject to penalties under federal law if I intentionally provide false or untrue information.

      •   I know that I must tell the Health Insurance Marketplace if anything changes (and is different than) what I wrote on this application. I can visit HealthCare.gov or call 1-800-318-2596 to report any changes. I understand that a change in my information could affect the eligibility for member(s) of my household.

      •   I know that under federal law, discrimination isn’t permitted on the basis of race, color, national origin, sex, age, sexual orientation, gender identity, or disability. I can file a complaint of discrimination by visiting www.hhs.gov/ocr/office/file.

      •   I know that my information on this form will be used only to determine eligibility for health coverage and will be kept private as required by law.

      •   I confirm that no one applying for health insurance on this application is incarcerated (detained or jailed).

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    • Confidentiality Notice: This application, and any attachments hereto, are for the sole use of the intended recipients, and may contain confidential and proprietary information. Any unauthorized use, disclosure or distribution of this application or its attachments is prohibited.
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