Application for Health Insurance - cahba.com

1 Application for Health InsuranceTMCovered California is the place where individuals and families can JHW D RUGDEOH KHDOWK LQVXUDQFH :LWK MXVW RQH DSSOLFDWLRQ \RX OO QG RXW LI \RX TXDOLI\ IRU IUHH RU ORZ FRVW KHDOWK LQVXUDQFH LQFOXGLQJ 0 HGL &DO The state of California created Covered California to help you and your family get Health Insurance . +DYLQJ KHDOWK LQVXUDQFH FDQ JLYH \RX SHDFH RI PLQG DQG KHOS PDNH LW SRVVLEOH IRU \RX WR VWD\ KHDOWK\ :LWK LQVXUDQFH \RX OO NQRZ \RX DQG \RXU IDPLO\ FDQ JHW KHDOWK FDUH ZKHQ \RX QHHG LW Use this Application to see what Insurance choices you qualify for: )UHH RU ORZ FRVW LQVXUDQFH IURP 0 HGL &DO /RZ FRVW LQVXUDQFH IRU SUHJQDQW ZRPHQ WKURXJK $FFHVV IRU QIDQWV DQG 0 RWKHUV $ 0 $IIRUGDEOH SULYDWH KHDOWK LQVXUDQFH SODQV +HOS SD\LQJ IRU \RXU KHDOWK LQVXUDQFH <RX PD\ TXDOLI\ IRU D IUHH RU ORZ FRVW SURJUDP HYHQ LI \RX HDUQ DV PXFK DV D \HDU IRU D IDPLO\ RI <RX FDQ XVH WKLV DSSOLFDWLRQ WR DSSO\ IRU DQ\RQH LQ \RXU IDPLO\ HYHQ LI WKH\ DOUHDG\ KDYH LQVXUDQFH QRZ Apply faster through Covered California at Or call: 1-800-300-1506 (TTY.

2 1-888-889-4500) You can call Monday to Friday, 8 to 8 , and Saturday, 8 to 6 You can get this Application in other languagesEspa ol 1-800-300-0213 1-800-300-15337L QJ 9L W 1-800-652-9528 1-800-738-91167 DJDORJ 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&DOO WR get this Application in RWKHU IRUPDWV VXFK DV ODUJH SULQW See Inside7 KLQJV WR NQRZ $SSOLFDWLRQ $WWDFKPHQWV $ ) )UHTXHQWO\ $VNHG 4 XHVWLRQV )$4 Your destination for affordable Health Insurance , including Medi-Cal67$7( 2) &$/ )251 $ +HDOWK QVXUDQFH $SSOLFDWLRQ | &&)50 CCFRM604 (11/13) ENCall Covered California at 1-800-300-1506 (TTY: 1-888-889-4500).

3 The call is free. You can call Monday to Friday, 8 to 8 , and Saturday, 8 to 6 Or visit help?1 Things to knowWhat you need to know when you apply 6 RFLDO 6 HFXULW\ QXPEHUV IRU DSSOLFDQWV ZKR DUH 8 6 FLWL]HQV RU GRFXPHQW information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e keep your information private and secure, as required by law.]]

4 :H OO XVH \RXU LQIRUPDWLRQ RQO\ WR VHH LI \RX TXDOLI\ IRU KHDOWK LQVXUDQFH )DPLOLHV WKDW LQFOXGH LPPLJUDQWV FDQ DSSO\ <RX FDQ DSSO\ IRU \RXU FKLOG HYHQ LI \RX DUHQ W HOLJLEOH IRU FRYHUDJH $SSO\LQJ IRU \RXU HOLJLEOH FKLOG ZRQ W DIIHFW \RXU LPPLJUDWLRQ VWDWXV RU FKDQFHV RI EHFRPLQJ D SHUPDQHQW UHVLGHQW RU FLWL]HQ I \RX GRQ W ILOH WD[HV \RX FDQ VWLOO TXDOLI\ IRU IUHH RU ORZ FRVW LQVXUDQFH WKURXJK 0 HGL &DO I \RX DUH D IHGHUDOO\ UHFRJQL]HG $PHULFDQ QGLDQ RU $ODVND 1 DWLYH ZKR LV JHWWLQJ VHUYLFHV IURP WKH QGLDQ +HDOWK 6 HUYLFHV WULEDO KHDOWK SURJUDPV RU XUEDQ QGLDQ KHDOWK SURJUDPV \RX PD\ VWLOO TXDOLI\ IRU KHDOWK LQVXUDQFH WKURXJK &RYHUHG &DOLIRUQLD Apply faster online$SSO\ RQOLQH DW W V VDIH VHFXUH DQG IDVW DQG \RX ZLOO JHW results sooner!

5 When you re done 6 HQG \RXU FRPSOHWHG DQG VLJQHG DSSOLFDWLRQ WR Covered California3 2 %R[ :HVW 6 DFUDPHQWR &$ If you don t have all the information we ask for, sign and send in your Application anyway. :H FDQ FDOO \RX WR KHOS \RX ILQLVK \RXU DSSOLFDWLRQ Do not send your Health Insurance plan enrollment payment with this Application . <RXU SODQ ZLOO VHQG \RX DQ LQYRLFH IRU WKH DPRXQW \RX RZH Get help with this Application :H UH KHUH WR KHOS \RX <RX FDQ JHW KHOS DW QR FRVW 2 QOLQH &RYHUHG&$ FRP 3 KRQH Call our Customer Service Center at 1-800-300-1506 77< 7KH FDOO LV IUHH <RX FDQ FDOO 0 RQGD\ WR )ULGD\ D P WR S P DQG 6 DWXUGD\ D P WR S P Q SHUVRQ :H KDYH WUDLQHG &HUWLILHG (QUROOPHQW &RXQVHORUV DQG &HUWLILHG QVXUDQFH $JHQWV ZKR FDQ KHOS \RX )RU D OLVW RI &HUWLILHG (QUROOPHQW &RXQVHORUV DQG &HUWLILHG QVXUDQFH $JHQWV QHDU ZKHUH \RX OLYH RU ZRUN RU D OLVW RI FRXQW\ VRFLDO VHUYLFHV RIILFHV QHDU \RX YLVLW &RYHUHG&$ FRP or call 1-800-300-1506 77< 7 KLV KHOS LV IUHH I \RX KDYH D GLVDELOLW\ RU RWKHU QHHG ZH FDQ SURYLGH DVVLVWDQFH ZLWK FRPSOHWLQJ WKLV DSSOLFDWLRQ DW QR FRVW WR \RX <RX FDQ JR WR \RXU ORFDO FRXQW\ VRFLDO VHUYLFHV RIILFH LQ person or call our Customer Service Center at 1-800-300-1506 77< CCFRM604 (11/13) EN Preguntas?]

6 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 8 y los s bados de 8 a 6 O visite 1: Tell us about the adult who will be our main contact for this Application )LUVW QDPH 0 LGGOH QDPH /DVW QDPH 6 XIIL[ (examples: Sr., Jr., III, IV) Home DGGUHVV $SDUWPHQW &LW\ (home address) State= 3 FRGH&RXQW\ &KHFN KHUH LI \RX GR QRW KDYH D KRPH DGGUHVV <RX PXVW JLYH XV D PDLOLQJ DGGUHVV EHORZ &KHFN KHUH LI \RXU PDLOLQJ DGGUHVV LV WKH VDPH DV \RXU KRPH DGGUHVV If it is not the same \RX PXVW JLYH XV \RXU PDLOLQJ DGGUHVV EHORZ Mailing DGGUHVV RU 3 2 ER[ LI GL HUHQW IURP KRPH DGGUHVV $SDUWPHQW &LW\ PDLOLQJ DGGUHVV State= 3 FRGH&RXQW\%HVW SKRQH QXPEHU WR UHDFK \RX Home Cell :RUN1 XPEHU ( ) 2 WKHU SKRQH QXPEHU Home Cell :RUN1 XPEHU ( ) :KDW ODQJXDJH VKRXOG ZH ZULWH WR \RX LQ".]]

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8 The call is free. You can call Monday to Friday, 8 to 8 , and Saturday, 8 to 6 Or visit help? Person 1 7 HOO XV DERXW yourself.)LUVW QDPH 0 LGGOH QDPH /DVW QDPH Suffix (examples: Sr., Jr., III, IV)5 HODWLRQVKLS WR \RX Self$UH \RX 0 DOH Female$UH \RX Single 1 HYHU PDUULHG 0 DUULHG Divorced Registered domestic partner :LGRZHG'DWH RI ELUWK PRQWK GD\ \HDU $UH \RX SUHJQDQW" Yes 1R If yes, KRZ PDQ\ EDELHV DUH H[SHFWHG" _____ :KDW LV WKH H[SHFWHG GHOLYHU\ GDWH" _____$SSO\LQJ IRU KHDOWK LQVXUDQFH (YHQ LI \RX KDYH LQVXUDQFH QRZ \RX PLJKW ILQG EHWWHU FRYHUDJH RU ORZHU FRVWV f $UH \RX DSSO\LQJ IRU KHDOWK LQVXUDQFH IRU \RXUVHOI" Yes If yes.]]

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