Fillable Application for Health Coverage (State of Louisiana - Office of Technology Services)

Fill Online, Printable, Fillable, Blank Application for Health Coverage (State of Louisiana - Office of Technology Services) Form

Use Fill to complete blank online STATE OF LOUISIANA - OFFICE OF TECHNOLOGY SERVICES (LA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Application for Health Coverage (State of Louisiana - Office of Technology Services)

On average this form takes 242 minutes to complete

The Application for Health Coverage (State of Louisiana - Office of Technology Services) form is 37 pages long and contains:

  • 0 signatures
  • 192 check-boxes
  • 879 other fields

Country of origin: US
File type: PDF

U.S.A. forms for State of Louisiana - Office of Technology Services

BROWSE STATE OF LOUISIANA - OFFICE OF TECHNOLOGY SERVICES (LA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
NEED HELP WITH YOUR APPLICATION? Visit www.medicaid.la.gov or call us at 1-888-342-6207. If you need help in a language other than
English, call 1-888-342-6207 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users
should call 1-800-220-5404.
Application for Health Coverage
THINGS TO KNOW
Use this application
to see what
coverage choices
you qualify for
• Aordable private health insurance plans that oer 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 Louisiana Children’s
Health Insurance Program (LaCHIP)
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).
Who can use this
application?
• Use this application to apply for anyone in your family.
• Apply even if you or your child already has health coverage. You could
be eligible for lower-cost or free coverage.
• Families that include immigrants can apply. You can apply for your
child even if you aren’t eligible for coverage. Applying won’t aect
your immigration status or chances of becoming a permanent resident
or citizen.
Apply faster
online
Apply faster online at www.medicaid.la.gov.
What you may
need to apply
• Social Security Numbers (or document numbers for any legal
immigrants who need insurance)
• Employer and income information for everyone in your family (for
example, from paystubs, W-2 forms, or wage and tax statements)
• Policy numbers for any current health insurance
• Information about any job-related health insurance available to
your family
Why do we ask for
this information?
We ask about income and other information to let you know what
coverage you qualify for and if you can get any help paying for it. We’ll
keep all the information you provide private and secure, as required
by law.
What happens next?
Send your complete, signed application to the address on page 12.
If you don’t have all the information we ask for, sign and submit
your application anyway. We’ll follow-up with you within 1–2 weeks.
You’ll get instructions on any further steps to take. If you don’t hear from us,
visit www.medicaid.la.gov or call 1-888-342-6207. Filling out this application
doesn’t mean you have to buy health coverage.
Get help with this
application
• Online: www.medicaid.la.gov
• Phone: Call us at 1-888-342-6207.
• In person: Visit our website or call 1-888-342-6207 to nd the Medicaid
oce closest to you.
• ¿Necesita traductor de español? Llame al 1-888-342-6207.
• Quí vị có cần thông dịch viên người Việt không? Nếu cần xin gọi số
1-888-342-6207.
BHSF Form 1-A
Revised 7/1/2021
THIS PAGE INTENTIONALLY
LEFT BLANK.
Page 1 of 12
NEED HELP WITH YOUR APPLICATION? Visit www.medicaid.la.gov or call us at 1-888-342-6207. If you need help in a language other than
English, call 1-888-342-6207 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users
should call 1-800-220-5404.
STEP 1
(We need one adult in the family to be the contact person for your application.)
1. First name, Middle name, Last name, & Suffix
2. Home address (Leave blank if you don’t have one) 3. Apartment or suite number
4. City 5. State 6. ZIP code 7. Parish
8. Mailing address (if different from home address) 9. Apartment or suite number
10. City 11. State 12. ZIP code 13. Parish
14. Phone number
(
)
–
15. Other phone number
(
)
–
16. Do you want to get information about this application by e-mail?
Yes
 
No
E-mail address:
17. What is your preferred spoken or written language (if not English)?
STEP 2
Who do you need to include on this application?
Tell us about all the family members who live with you. If you le taxes, we need to know about everyone on your tax return.
(You don’t need to le taxes to get health coverage).
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 don’t
live with you
• 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 le their own tax return
(if you’re over 21)
• Other adult relatives who le their own tax return
The amount of assistance or type of program you qualify for depends on the number of people in your family and their incomes.
This information helps us make sure everyone gets the best coverage they can.
Complete Step 2 for each person in your family. Start with yourself, then add other adults and children. If you have more
than 4 people in your family, you’ll need to make a copy of the pages and attach them. You don’t need to provide immigration
status or a Social Security Number (SSN) for family members who don’t need health coverage. We’ll keep all the information you
provide private and secure as required by law. We’ll use personal information only to check if you’re eligible for health coverage.
Tell us about yourself
Tell us about your family
Page 2 of 12
NEED HELP WITH YOUR APPLICATION? Visit www.medicaid.la.gov or call us at 1-888-342-6207. If you need help in a language other than
English, call 1-888-342-6207 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users
should call 1-800-220-5404.
STEP 2: PERSON 1
Complete Step 2 for yourself, your spouse/partner, and children who live with you and/or anyone on your same federal income tax return if you le
one. See page 1 for more information about who to include. If you don’t le a tax return, remember to still add family members who live with you.
1. First name, Middle name, Last name, & Suffix
2. Date of birth (mm/dd/yyyy)
3. Sex
Male 
Female
4. Social Security number (SSN)
- -
We need this if you want health coverage and have an SSN. We only use SSNs to check income and other information from other
government agencies, financial institutions, and other sources to see who’s eligible for help with health coverage costs. Providing your SSN
can be helpful even if you don’t want health coverage, and can speed up the application process. If someone wants help getting an SSN, call
1-800-772-1213 or visit www.socialsecurity.gov. TTY users should call 1-800-325-0778.
5. If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.)
Mexican  Mexican American  Chicano/a 
Puerto Rican 
Cuban 
Other
6. Race (OPTIONAL—check all that apply.)
White
Black or African
American
American Indian or
Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacic Islander
Other
7. Do you plan to file a federal income tax return NEXT YEAR?
(You can still apply for health insurance even if you don’t file a federal income tax return.)
YES. If yes, answer questions a–c. NO. If no, skip to question c.
a. Will you le jointly with a spouse?
Yes 
No
If yes, name of spouse:
b. Will you claim any dependents on your tax return?
Yes 
No
If yes, list name(s) of dependents:
c. Will you be claimed as a dependent on someone’s tax return?
Yes 
No
If yes, please list the name of the tax ler:
How are you related to the tax ler?
8. Are you pregnant?
Yes 
No If yes, how many babies are expected during this pregnancy?
9. Do you need health coverage?
(Even if you have insurance, there might be a program with better coverage or lower costs.)
YES. If yes, answer all the questions below.
NO. If no, SKIP to the income questions on page 3.
10. Do you have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc.)?
Yes 
No If yes, you’ll need to complete and include Appendix D.
11. Do you live in a medical facility or nursing home?
Yes 
No If yes, you’ll need to complete and include Appendix D.
12.
Do you want help paying for medical bills (paid or unpaid) for
medical care received in the past 3 months?
Yes 
No
13. Do you live with at least one child under the age of 19, and are
you the main person taking care of this child?
Yes 
No
14. Were you in foster care at age 18 or older?
Yes 
No
a. If yes, in which state?   b. Were you on Medicaid?
Yes 
No  c. How old were you when you left foster care?
15. Did you have insurance through a job and lose it within the past 6 months?
Yes 
No
a. If yes, end date: b. Reason the insurance ended:
16. Are you a full-time student?
Yes 
No
17. Are you a U.S. citizen or U.S. national?
Yes 
No
If yes, were you born in the U.S. or a U.S. territory?
Yes 
No If no, fill in your information below (if it applies to you).
a. Alien number  b. Certificate type  c. Certificate number
If no, do you have eligible immigration status? Yes  No If yes, fill in your information below (if it applies to you).
a. Document type b. Document expiration date (mm/dd/yyyy)
c. Alien, I-94, or SEVIS ID number d. Card or Passport number
e. Have you lived in the U.S. since 1996?
Yes 
No f. Are you or your spouse or parent a veteran or an active-duty
member of the U.S. military?
Yes 
No
(Start with yourself)
Page 3 of 12
NEED HELP WITH YOUR APPLICATION? Visit www.medicaid.la.gov or call us at 1-888-342-6207. If you need help in a language other than
English, call 1-888-342-6207 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users
should call 1-800-220-5404.
CURRENT JOB 1:
18. Employer name and address 19. Employer phone number
(
)
–
20. Wages/tips (before taxes) Hourly  Weekly  Every 2 weeks  Twice a month  Monthly  Yearly
$
21. Average hours worked each WEEK
CURRENT JOB 2: (If you have more jobs and need more space, attach another sheet of paper.)
22. Employer name and address 23. Employer phone number
(
)
–
24. Wages/tips (before taxes) Hourly  Weekly  Every 2 weeks  Twice a month  Monthly  Yearly
$
25. Average hours worked each WEEK
26. In the past year, did you:
Change jobs 
Stop working 
Start working fewer hours 
None of these
27. If self-employed, answer the following questions:
a. Type of work
b. How much net income (profits or losses once business expenses
are paid) will you get from this self-employment this month?
$
28. OTHER INCOME THIS MONTH: Check all that apply, and give the amount and how often you get it.
None
Unemployment $ How often?
Pensions $ How often?
Social Security $ How often?
Retirement accounts $ How often?
Investments $ How often?
Alimony received $ How often?
Supplemental Security
Income (SSI) $ How often?
Child support $ How often?
Veteran’s payments $ How often?
Scholarships/Grants $ How often?
Capital Gains $ How often?
Net
farming/fishing $ How often?
Net rental/royalty $ How often?
Other income Type:
$ How often?
29.
DEDUCTIONS: Check all that apply, and give the amount and how often you get it. If you pay for certain things that can be deducted on a
federal income tax return, telling us about them could make the cost of health coverage a little lower.
NOTE: You shouldn’t include a cost that you already considered in your answer to net self-employment (question 27b).
Alimony paid $ How often?
Student loan interest $ How often?
Other deductions Type:
$ How often?
30. YEARLY INCOME: Complete only if your income changes from month to month. If you don’t expect changes to your monthly income,
skip to the next person.
Your total income this year
$
Your total income next year (if you think it will be dierent)
$
THANKS! This is all we need to know about you.
STEP 2: PERSON 1
(Continue with yourself)
Current Job & Income Information
Employed
If you’re currently employed, tell us
about your income. Start with
question 18..
Not employed
Skip to question 28.
Self-employed
Skip to question 27.
Page 4 of 12
NEED HELP WITH YOUR APPLICATION? Visit www.medicaid.la.gov or call us at 1-888-342-6207. If you need help in a language other than
English, call 1-888-342-6207 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users
should call 1-800-220-5404.
STEP 2: PERSON 2
Complete Step 2 for yourself, your spouse/partner, and children who live with you and/or anyone on your same federal income tax return if you le
one. See page 1 for more information about who to include. If you don’t le a tax return, remember to still add family members who live with you.
1. First name, Middle name, Last name, & Suffix 5. Relationships
(examples: mother, father, daughter, son, etc.)
This person’s relationship to:
PERSON 1:
2. Date of birth (mm/dd/yyyy)
3. Sex
Male 
Female
4. Social Security number (SSN)
- -
We need this if PERSON 2 wants health coverage and has an SSN.
6. Does PERSON 2 live at the same address as you?
Yes 
No
If no, list address:
7. If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.)
Mexican  Mexican American  Chicano/a 
Puerto Rican 
Cuban 
Other
8. Race (OPTIONAL—check all that apply.)
White
Black or African
American
American Indian or
Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacic Islander
Other
9. Does PERSON 2 plan to file a federal income tax return NEXT YEAR?
(You can still apply for health insurance even if you don’t file a federal income tax return.)
YES. If yes, answer questions a–c. NO. If no, skip to question c.
a. Will PERSON 2 le jointly with a spouse?
Yes 
No
If yes, name of spouse:
b. Will PERSON 2 claim any dependents on their tax return?
Yes 
No
If yes, list name(s) of dependents:
c. Will PERSON 2 be claimed as a dependent on someone’s tax return?
Yes 
No
If yes, please list the name of the tax ler:
How is PERSON 2 related to the tax ler?
10. Is PERSON 2 pregnant?
Yes 
No If yes, how many babies are expected during this pregnancy?
11. Does PERSON 2 need health coverage?
(Even if you have insurance, there might be a program with better coverage or lower costs.)
YES. If yes, answer all the questions below.
NO. If no, SKIP to the income questions on page 5.
12. Does PERSON 2 have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily
chores, etc.)?
Yes 
No If yes, you’ll need to complete and include Appendix D.
13. Does PERSON 2 live in a medical facility or nursing home?
Yes 
No If yes, you’ll need to complete and include Appendix D.
14.
Does PERSON 2 want help paying for medical bills (paid or unpaid)
for medical care received in the past 3 months?
Yes 
No
15. Does PERSON 2 live with at least one child under the age of 19, and
are they the main person taking care of this child?
Yes 
No
16. Was PERSON 2 in foster care at age 18 or older?
Yes 
No
a. If yes, in which state?  b. Were they on Medicaid?
Yes 
No c. How old was PERSON 2 when they left foster care?
17. Did PERSON 2 have insurance through a job and lose it within the past 6 months?
Yes 
No
a. If yes, end date: b. Reason the insurance ended:
18. Is PERSON 2 a full-time student?
Yes 
No
19. Is PERSON 2 a U.S. citizen or U.S. national?
Yes 
No
If yes, was PERSON 2 born in the U.S. or a U.S. territory?
Yes 
No If no, fill in their information below (if it applies to them).
a. Alien number  b. Certificate type  c. Certificate number
If no, does PERSON 2 have eligible immigration status? Yes  No If yes, fill in their information below (if it applies to them).
a. Document type b. Document expiration date (mm/dd/yyyy)
c. Alien, I-94, or SEVIS ID number d. Card or Passport number
e. Has PERSON 2 lived in the U.S. since 1996?
Yes 
No f. Is PERSON 2 or their spouse or parent a veteran or an active-duty
member of the U.S. military?
Yes 
No
Page 5 of 12
NEED HELP WITH YOUR APPLICATION? Visit www.medicaid.la.gov or call us at 1-888-342-6207. If you need help in a language other than
English, call 1-888-342-6207 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users
should call 1-800-220-5404.
STEP 2: PERSON 2
(Continue with PERSON 2)
CURRENT JOB 1:
20. Employer name and address 21. Employer phone number
(
)
–
22. Wages/tips (before taxes) Hourly  Weekly  Every 2 weeks  Twice a month  Monthly  Yearly
$
23. Average hours worked each WEEK
CURRENT JOB 2: (If PERSON 2 has more jobs and you need more space, attach another sheet of paper.)
24. Employer name and address 25. Employer phone number
(
)
–
26. Wages/tips (before taxes) Hourly  Weekly  Every 2 weeks  Twice a month  Monthly  Yearly
$
27. Average hours worked each WEEK
28. In the past year, did PERSON 2:
Change jobs 
Stop working 
Start working fewer hours 
None of these
29. If self-employed, answer the following questions:
a. Type of work
b. How much net income (profits or losses once business expenses
are paid) will PERSON 2 get from this self-employment this month?
$
30. OTHER INCOME THIS MONTH: Check all that apply, and give the amount and how often PERSON 2 gets it.
None
Unemployment $ How often?
Pensions $ How often?
Social Security $ How often?
Retirement accounts $ How often?
Investments $ How often?
Alimony received $ How often?
Supplemental Security
Income (SSI) $ How often?
Child support $ How often?
Veteran’s payments $ How often?
Scholarships/Grants $ How often?
Capital Gains $ How often?
Net
farming/fishing $ How often?
Net rental/royalty $ How often?
Other income Type:
$ How often?
31.
DEDUCTIONS: Check all that apply, and give the amount and how often PERSON 2 gets it. If PERSON 2 pays for certain things that can be
deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower.
NOTE: You shouldn’t include a cost that you already considered in PERSON 2’s answer to net self-employment (question 29b).
Alimony paid $ How often?
Student loan interest $ How often?
Other deductions Type:
$ How often?
32. YEARLY INCOME: Complete only if PERSON 2’s income changes from month to month. If you don’t expect changes to PERSON 2’s
monthly income, skip to the next person.
PERSON 2’s total income this year
$
PERSON 2’s total income next year (if you think it will be dierent)
$
THANKS! This is all we need to know about PERSON 2.
Current Job & Income Information
Employed
If PERSON 2 is currently employed,
tell us about their income. Start with
question 20..
Not employed
Skip to question 30.
Self-employed
Skip to question 29.
Page 6 of 12
NEED HELP WITH YOUR APPLICATION? Visit www.medicaid.la.gov or call us at 1-888-342-6207. If you need help in a language other than
English, call 1-888-342-6207 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users
should call 1-800-220-5404.
STEP 2: PERSON 3
Complete Step 2 for yourself, your spouse/partner, and children who live with you and/or anyone on your same federal income tax return if you le
one. See page 1 for more information about who to include. If you don’t le a tax return, remember to still add family members who live with you.
1. First name, Middle name, Last name, & Suffix 5. Relationships
(examples: mother, father, daughter, son, etc.)
This person’s relationship to:
PERSON 1:
PERSON 2:
2. Date of birth (mm/dd/yyyy)
3. Sex
Male 
Female
4. Social Security number (SSN)
- -
We need this if PERSON 3 wants health coverage and has an SSN.
6. Does PERSON 3 live at the same address as you?
Yes 
No
If no, list address:
7. If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.)
Mexican  Mexican American  Chicano/a 
Puerto Rican 
Cuban 
Other
8. Race (OPTIONAL—check all that apply.)
White
Black or African
American
American Indian or
Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacic Islander
Other
9. Does PERSON 3 plan to file a federal income tax return NEXT YEAR?
(You can still apply for health insurance even if you don’t file a federal income tax return.)
YES. If yes, answer questions a–c. NO. If no, skip to question c.
a. Will PERSON 3 le jointly with a spouse?
Yes 
No
If yes, name of spouse:
b. Will PERSON 3 claim any dependents on their tax return?
Yes 
No
If yes, list name(s) of dependents:
c. Will PERSON 3 be claimed as a dependent on someone’s tax return?
Yes 
No
If yes, please list the name of the tax ler:
How is PERSON 3 related to the tax ler?
10. Is PERSON 3 pregnant?
Yes 
No If yes, how many babies are expected during this pregnancy?
11. Does PERSON 3 need health coverage?
(Even if you have insurance, there might be a program with better coverage or lower costs.)
YES. If yes, answer all the questions below.
NO. If no, SKIP to the income questions on page 7.
12. Does PERSON 3 have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily
chores, etc.)?
Yes 
No If yes, you’ll need to complete and include Appendix D.
13. Does PERSON 3 live in a medical facility or nursing home?
Yes 
No If yes, you’ll need to complete and include Appendix D.
14.
Does PERSON 3 want help paying for medical bills (paid or unpaid)
for medical care received in the past 3 months?
Yes 
No
15. Does PERSON 3 live with at least one child under the age of 19, and
are they the main person taking care of this child?
Yes 
No
16. Was PERSON 3 in foster care at age 18 or older?
Yes 
No
a. If yes, in which state?  b. Were they on Medicaid?
Yes 
No c. How old was PERSON 3 when they left foster care?
17. Did PERSON 3 have insurance through a job and lose it within the past 6 months?
Yes 
No
a. If yes, end date: b. Reason the insurance ended:
18. Is PERSON 3 a full-time student?
Yes 
No
19. Is PERSON 3 a U.S. citizen or U.S. national?
Yes 
No
If yes, was PERSON 3 born in the U.S. or a U.S. territory?
Yes 
No If no, fill in their information below (if it applies to them).
a. Alien number  b. Certificate type  c. Certificate number
If no, does PERSON 3 have eligible immigration status? Yes  No If yes, fill in their information below (if it applies to them).
a. Document type b. Document expiration date (mm/dd/yyyy)
c. Alien, I-94, or SEVIS ID number d. Card or Passport number
e. Has PERSON 3 lived in the U.S. since 1996?
Yes 
No f. Is PERSON 3 or their spouse or parent a veteran or an active-duty
member of the U.S. military?
Yes 
No
Page 7 of 12
NEED HELP WITH YOUR APPLICATION? Visit www.medicaid.la.gov or call us at 1-888-342-6207. If you need help in a language other than
English, call 1-888-342-6207 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users
should call 1-800-220-5404.
STEP 2: PERSON 3
(Continue with PERSON 3)
CURRENT JOB 1:
20. Employer name and address 21. Employer phone number
(
)
–
22. Wages/tips (before taxes) Hourly  Weekly  Every 2 weeks  Twice a month  Monthly  Yearly
$
23. Average hours worked each WEEK
CURRENT JOB 2: (If PERSON 3 has more jobs and you need more space, attach another sheet of paper.)
24. Employer name and address 25. Employer phone number
(
)
–
26. Wages/tips (before taxes) Hourly  Weekly  Every 2 weeks  Twice a month  Monthly  Yearly
$
27. Average hours worked each WEEK
28. In the past year, did PERSON 3:
Change jobs 
Stop working 
Start working fewer hours 
None of these
29. If self-employed, answer the following questions:
a. Type of work
b. How much net income (profits or losses once business expenses
are paid) will PERSON 3 get from this self-employment this month?
$
30. OTHER INCOME THIS MONTH: Check all that apply, and give the amount and how often PERSON 3 gets it.
None
Unemployment $ How often?
Pensions $ How often?
Social Security $ How often?
Retirement accounts $ How often?
Investments $ How often?
Alimony received $ How often?
Supplemental Security
Income (SSI) $ How often?
Child support $ How often?
Veteran’s payments $ How often?
Scholarships/Grants $ How often?
Capital Gains $ How often?
Net
farming/fishing $ How often?
Net rental/royalty $ How often?
Other income Type:
$ How often?
31.
DEDUCTIONS: Check all that apply, and give the amount and how often PERSON 3 gets it. If PERSON 3 pays for certain things that can be
deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower.
NOTE: You shouldn’t include a cost that you already considered in PERSON 3’s answer to net self-employment (question 29b).
Alimony paid $ How often?
Student loan interest $ How often?
Other deductions Type:
$ How often?
32. YEARLY INCOME: Complete only if PERSON 3's income changes from month to month. If you don’t expect changes to PERSON 3's
monthly income, skip to the next person.
PERSON 3’s total income this year
$
PERSON 3’s total income next year (if you think it will be dierent)
$
THANKS! This is all we need to know about PERSON 3.
Current Job & Income Information
Employed
If PERSON 3 is currently employed,
tell us about their income. Start with
question 20..
Not employed
Skip to question 30.
Self-employed
Skip to question 29.
Page 8 of 12
NEED HELP WITH YOUR APPLICATION? Visit www.medicaid.la.gov or call us at 1-888-342-6207. If you need help in a language other than
English, call 1-888-342-6207 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users
should call 1-800-220-5404.
STEP 2: PERSON 4
Complete Step 2 for yourself, your spouse/partner, and children who live with you and/or anyone on your same federal income tax return if you le
one. See page 1 for more information about who to include. If you don’t le a tax return, remember to still add family members who live with you.
1. First name, Middle name, Last name, & Suffix 5. Relationships
(examples: mother, father, daughter, son, etc.)
This person’s relationship to:
PERSON 1:
PERSON 2:
PERSON 3:
2. Date of birth (mm/dd/yyyy)
3. Sex
Male 
Female
4. Social Security number (SSN)
- -
We need this if PERSON 4 wants health coverage and has an SSN.
6. Does PERSON 4 live at the same address as you?
Yes 
No
If no, list address:
7. If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.)
Mexican  Mexican American  Chicano/a 
Puerto Rican 
Cuban 
Other
8. Race (OPTIONAL—check all that apply.)
White
Black or African
American
American Indian or
Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacic Islander
Other
9. Does PERSON 4 plan to file a federal income tax return NEXT YEAR?
(You can still apply for health insurance even if you don’t file a federal income tax return.)
YES. If yes, answer questions a–c. NO. If no, skip to question c.
a. Will PERSON 4 le jointly with a spouse?
Yes 
No
If yes, name of spouse:
b. Will PERSON 4 claim any dependents on their tax return?
Yes 
No
If yes, list name(s) of dependents:
c. Will PERSON 4 be claimed as a dependent on someone’s tax return?
Yes 
No
If yes, please list the name of the tax ler:
How is PERSON 4 related to the tax ler?
10. Is PERSON 4 pregnant?
Yes 
No If yes, how many babies are expected during this pregnancy?
11. Does PERSON 4 need health coverage?
(Even if you have insurance, there might be a program with better coverage or lower costs.)
YES. If yes, answer all the questions below.
NO. If no, SKIP to the income questions on page 9.
12. Does PERSON 4 have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily
chores, etc.)?
Yes 
No If yes, you’ll need to complete and include Appendix D.
13. Does PERSON 4 live in a medical facility or nursing home?
Yes 
No If yes, you’ll need to complete and include Appendix D.
14.
Does PERSON 4 want help paying for medical bills (paid or unpaid)
for medical care received in the past 3 months?
Yes 
No
15. Does PERSON 4 live with at least one child under the age of 19, and
are they the main person taking care of this child?
Yes 
No
16. Was PERSON 4 in foster care at age 18 or older?
Yes 
No
a. If yes, in which state?  b. Were they on Medicaid?
Yes 
No c. How old was PERSON 4 when they left foster care?
17. Did PERSON 4 have insurance through a job and lose it within the past 6 months?
Yes 
No
a. If yes, end date: b. Reason the insurance ended:
18. Is PERSON 4 a full-time student?
Yes 
No
19. Is PERSON 4 a U.S. citizen or U.S. national?
Yes 
No
If yes, was PERSON 4 born in the U.S. or a U.S. territory?
Yes 
No If no, fill in their information below (if it applies to them).
a. Alien number  b. Certificate type  c. Certificate number
If no, does PERSON 4 have eligible immigration status? Yes  No If yes, fill in their information below (if it applies to them).
a. Document type b. Document expiration date (mm/dd/yyyy)
c. Alien, I-94, or SEVIS ID number d. Card or Passport number
e. Has PERSON 4 lived in the U.S. since 1996?
Yes 
No f. Is PERSON 4 or their spouse or parent a veteran or an active-duty
member of the U.S. military?
Yes 
No
Page 9 of 12
NEED HELP WITH YOUR APPLICATION? Visit www.medicaid.la.gov or call us at 1-888-342-6207. If you need help in a language other than
English, call 1-888-342-6207 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users
should call 1-800-220-5404.
STEP 2: PERSON 4
(Continue with PERSON 4)
CURRENT JOB 1:
20. Employer name and address 21. Employer phone number
(
)
–
22. Wages/tips (before taxes) Hourly  Weekly  Every 2 weeks  Twice a month  Monthly  Yearly
$
23. Average hours worked each WEEK
CURRENT JOB 2: (If PERSON 4 has more jobs and you need more space, attach another sheet of paper.)
24. Employer name and address 25. Employer phone number
(
)
–
26. Wages/tips (before taxes) Hourly  Weekly  Every 2 weeks  Twice a month  Monthly  Yearly
$
27. Average hours worked each WEEK
28. In the past year, did PERSON 4:
Change jobs 
Stop working 
Start working fewer hours 
None of these
29. If self-employed, answer the following questions:
a. Type of work
b. How much net income (profits or losses once business expenses
are paid) will PERSON 4 get from this self-employment this month?
$
30. OTHER INCOME THIS MONTH: Check all that apply, and give the amount and how often PERSON 4 gets it.
None
Unemployment $ How often?
Pensions $ How often?
Social Security $ How often?
Retirement accounts $ How often?
Investments $ How often?
Alimony received $ How often?
Supplemental Security
Income (SSI) $ How often?
Child support $ How often?
Veteran’s payments $ How often?
Scholarships/Grants $ How often?
Capital Gains $ How often?
Net
farming/fishing $ How often?
Net rental/royalty $ How often?
Other income Type:
$ How often?
31.
DEDUCTIONS: Check all that apply, and give the amount and how often PERSON 4 gets it. If PERSON 4 pays for certain things that can be
deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower.
NOTE: You shouldn’t include a cost that you already considered in PERSON 4’s answer to net self-employment (question 29b).
Alimony paid $ How often?
Student loan interest $ How often?
Other deductions Type:
$ How often?
32. YEARLY INCOME: Complete only if PERSON 4's income changes from month to month. If you don’t expect changes to PERSON 4's
monthly income, skip to the next person.
PERSON 4’s total income this year
$
PERSON 4’s total income next year (if you think it will be dierent)
$
THANKS! This is all we need to know about PERSON 4.
If you have more than four people to include, visit www.medicaid.la.gov to download and print additional pages
or make a copy of pages 8 and 9 and complete.
Current Job & Income Information
Employed
If PERSON 4 is currently employed,
tell us about their income. Start with
question 20..
Not employed
Skip to question 30.
Self-employed
Skip to question 29.
Page 10 of 12
NEED HELP WITH YOUR APPLICATION? Visit www.medicaid.la.gov or call us at 1-888-342-6207. If you need help in a language other than
English, call 1-888-342-6207 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users
should call 1-800-220-5404.
1. Are you or is anyone in your family American Indian or Alaska Native?
NO. If no, skip to Step 4.
YES. If yes, you’ll need to complete and include Appendix B.
STEP 3
Answer these questions for anyone who needs health coverage.
1. Is anyone enrolled in health coverage now from the following?
YES. If yes, check the type of coverage and write the person(s)’ name(s) next to the coverage they have. 
NO.
Medicaid
CHIP
Medicare
TRICARE (Don’t check if you have direct care or Line of Duty)
VA health care programs
Peace Corps
Employer insurance
Name of health insurance:
Policy number:
Is this COBRA coverage?
Yes 
No
Is this a retiree health plan?
Yes 
No
Other
Name of health insurance:
Policy number:
Is this a limited-benet plan (like a school accident policy)?
Yes 
No
2.
Is anyone listed on this application offered health coverage from a job? This could be from their own job or from someone else’s job,
such as a parent or spouse.
YES. If yes, you’ll need to complete and include Appendix A.
Is this a state employee benefit plan?
Yes 
No If yes, who can get coverage from it?
NO. If no, continue to Step 5.
STEP 4
Your Family’s Health Coverage
American Indian or Alaska Native (AI/AN) family member(s)
STEP 5
• I understand that I am 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 provide
false or untrue information. I have permission from all of the people listed on the application to both submit their information
to the Louisiana Department of Health (LDH) and receive any information about their eligibility and health coverage.
• I understand that LDH is authorized to gather the information requested in this application and any supporting documentation,
including social security numbers, under the Patient Protection and Aordable Care Act (Public Law No. 111-148), as
amended by the Health Care and Education Reconciliation Act of 2010 (Public Law No. 111-152), and the Social Security Act.
• I understand that providing the requested information (including social security numbers) is voluntary. However, failing to provide
it may delay or prevent me from getting health coverage through Medicaid or any other insurance aordability program.
• I understand that LDH will check the information I give them to make sure it is correct. I give LDH permission to contact any
outside source(s) necessary to check this information, process my application, determine eligibility, and otherwise operate the
Medicaid program. These outside sources may include:
- Federal agencies (such as the Internal Revenue Service,
Social Security Administration, and Department of
Homeland Security), other state agencies, and/or local
government agencies.
- Banks, nancial institutions, and consumer reporting agencies.
- Employers identied on applications for eligibility
determinations.
- Doctors or other medical providers.
- Applicants/enrollees, and authorized representatives of
applicants/enrollees.
- LDH contractors engaged to perform a function for the
Medicaid program.
- Anyone else as required or allowed by law.
Read & sign this application
Page 11 of 12
NEED HELP WITH YOUR APPLICATION? Visit www.medicaid.la.gov or call us at 1-888-342-6207. If you need help in a language other than
English, call 1-888-342-6207 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users
should call 1-800-220-5404.
STEP 5
• I give these outside sources permission to give LDH any information about me, or any person necessary for this application,
that it may request. I understand that this permission will end when this application is denied, when my Medicaid eligibility
ends, or when I submit a written statement to LDH canceling this permission, whichever comes rst. A cancellation may
prevent me from being found to be eligible for Medicaid.
• I understand the social security numbers will only be used to get information from these outside sources to verify income,
make eligibility determinations, or for other purposes directly connected to the administration of the Medicaid program.
• I know that I must tell Medicaid if anything changes (and is dierent than) what I wrote on this application. I can visit
www.medicaid.la.gov or call 1-888-342-6207 to report any changes. I understand that a change in my information could
aect 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 le a complaint of discrimination by visiting www.hhs.gov/ocr/oce/le, calling the US DHHS
Regional Oce for Civil Rights at 1-800-368-1019, or writing to the LDH at PO Box 4818, Baton Rouge, Louisiana 70821.
• I conrm that no one applying for health insurance on this application is incarcerated (detained or jailed), and if they are that
I must report it.
Is anyone applying for coverage on this application incarcerated (detained or jailed)?
Yes 
No If yes, who is incarcerated?:
Renewal of coverage in future years
To make it easier to determine my eligibility for help paying for health coverage in future years, I agree to allow Medicaid to
use income data, including information from tax returns. Medicaid will send me a notice, let me make any changes, and I can
opt out at any time.
Yes, renew my eligibility automatically for the next (choose one):
5 years 
4 years 
3 years 
2 years 
1 year
No, don’t use information from tax returns to renew my coverage.
If anyone on this application is eligible for Medicaid
By signing and submitting this application, I understand that if anyone on this application enrolls in Medicaid, I’m giving LDH our
rights to any money owed to us by any other health insurance, legal settlement, a spouse or parent, or other third party.
I know I’ll be asked to cooperate with the agency that collects medical support from an absent parent. If I think that
cooperating to collect medical support will harm me or my children, I can tell the agency and I may not have to cooperate.
Agree  Disagree (Selecting Disagree may impact your eligibility for Medicaid.)
Estate Recovery
I understand that Estate Recovery rules require Louisiana Medicaid to recover the cost of certain Medicaid payments from
the applicant’s estate. These costs include the total amount of payments for facility services, hospital care, payments to HCBS
or PACE providers, and prescription drugs received at age 55 or older. The estate is the property owned at the time of death.
Medicaid will not make a claim against the estate while the applicant or his or her legal spouse is still living. Medicaid also will
not make a claim if the applicant has a dependent child who is under age 21, blind, or disabled. Collection may not be made if it
is not cost eective for Medicaid to do so, or if it would cause a hardship for the heirs of the estate. A hardship may exist if the
estate property is the only source of income for the heirs, if that income is limited, or if there are other convincing situations.
My right to appeal
If I think the Health Insurance Marketplace or Louisiana Medicaid has made a mistake, I can appeal its decision. To appeal means
to tell someone at the Health Insurance Marketplace or Medicaid that I think the action is wrong, and ask for a fair review of the
action. I know that I can nd out how to appeal by contacting Medicaid at 1-888-342-6207. I know that I can be represented in the
process by someone other than myself. My eligibility and other important information will be explained to me.
Sign this application
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 provide the information required in Appendix C.
Signature Date (mm/dd/yyyy)
Read & sign this application (continued)
Page 12 of 12
NEED HELP WITH YOUR APPLICATION? Visit www.medicaid.la.gov or call us at 1-888-342-6207. If you need help in a language other than
English, call 1-888-342-6207 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users
should call 1-800-220-5404.
Mail your signed application to:
Medicaid Application Oce
P.O. Box 91278
Baton Rouge, LA 70821-9893
Fax your signed application to:
1-877-523-2987
STEP 6
Submit completed application
NEED HELP WITH YOUR APPLICATION? Visit www.medicaid.la.gov or call us at 1-888-342-6207. If you need help in a language other than
English, call 1-888-342-6207 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users
should call 1-800-220-5404.
Health Coverage from Jobs
You DON’T need to answer these questions unless someone in the household is eligible for health coverage from a job.
Attach a copy of this page for each job that oers coverage.
Tell us about the job that offers coverage.
Take the Employer Coverage Tool on the next page to the employer who oers coverage to help you answer these
questions. You only need to include this page when you send in your application, not the Employer Coverage Tool.
EMPLOYEE Information
1. Employee name (First, Middle, Last) 2. Employee Social Security number
- -
EMPLOYER Information
3. Employer name 4. Employer Identification Number (EIN)
-
5. Employer address 6. Employer phone number
(
)
–
7. City 8. State 9. ZIP code
10. Who can we contact about employee health coverage at this job?
11. Phone number (if dierent from above)
(
)
–
12. E-mail address
Tell us about the health plan offered by this employer.
14. Does the employer oer a health plan that meets the minimum value standard*?
Yes 
No
15.
For the lowest-cost plan that meets the minimum value standard* oered only to the employee (don’t include family plans):
If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for
any tobacco cessation programs, and did not receive any other discounts based on wellness programs.
a. How much would the employee have to pay in premiums for this plan? $
b. How often? Weekly  Every 2 weeks  Twice a month  Once a month  Quarterly  Yearly
16. What change will the employer make for the new plan year (if known)?
Employer won’t offer health coverage.
Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to
the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.)
a. How much will the employee have to pay in premiums for that plan? $
b. How often? Weekly  Every 2 weeks  Twice a month  Once a month  Quarterly  Yearly
Date of change (mm/dd/yyyy):
* An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of the total allowed benet costs covered by the plan is no
less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)
13. Are you currently eligible for coverage oered by this employer, or will you become eligible in the next 3 months?
Yes (Continue)
13a. If you’re in a waiting or probationary period, when can you enroll in coverage?
List the names of anyone else who is eligible for coverage from this job.
Name: Name: Name:
No (Stop here and go to Step 5 in the application)
APPENDIX A
(mm/dd/yyyy)
NEED HELP WITH YOUR APPLICATION? Visit www.medicaid.la.gov or call us at 1-888-342-6207. If you need help in a language other than
English, call 1-888-342-6207 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users
should call 1-800-220-5404.
EMPLOYEE Information
The employee needs to ll out this section.
1. Employee name (First, Middle, Last) 2. Employee Social Security number
- -
EMPLOYER Information
Ask the employer for this information.
3. Employer name 4. Employer Identification Number (EIN)
-
5. Employer address 6. Employer phone number
(
)
–
7. City 8. State 9. ZIP code
10. Who can we contact about employee health coverage at this job?
11. Phone number (if dierent from above)
(
)
–
12. E-mail address
EMPLOYER COVERAGE TOOL
Use this tool to help answer questions in Appendix A about any employer health coverage that you’re eligible for (even if
it’s from another person’s job, like a parent or spouse). The information in the numbered boxes below match the boxes on
Appendix A. For example, the answer to question 14 on this page should match question 14 on Appendix A.
Write your name and Social Security number in boxes 1 and 2 and ask the employer to ll out the rest of the form.
Complete one tool for each employer that oers health coverage.
13. Is the employee currently eligible for coverage oered by this employer, or will the employee be eligible in the next 3 months?
Yes (Continue)
13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee eligible for
coverage? (mm/dd/yyyy)
No (STOP and return this form to employee)
Tell us about the health plan oered by this employer.
Does the employer oer a health plan that covers an employee’s spouse or dependent?
Yes 
No If yes, which people?
Spouse 
Dependent(s)
14. Does the employer oer a health plan that meets the minimum value standard*?
Yes (Go to question 15) 
No (STOP and return form to employee)
15.
For the lowest-cost plan that meets the minimum value standard* oered only to the employee (don’t include family plans): If the
employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for any
tobacco cessation programs, and didn’t receive any other discounts based on wellness programs.
a. How much would the employee have to pay in premiums for this plan? $
b. How often? Weekly  Every 2 weeks  Twice a month  Once a month  Quarterly  Yearly
If the plan year will end soon and you know that the health plans offered will change, go to question 16. If you don’t know, STOP and return
form to employee.
16. What change will the employer make for the new plan year?
Employer won’t offer health coverage
Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the
employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.)
a. How much will the employee have to pay in premiums for that plan? $
b. How often? Weekly  Every 2 weeks  Twice a month  Once a month  Quarterly  Yearly
Date of change (mm/dd/yyyy):
* An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of the total allowed benet costs covered by the plan is no
less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)
NEED HELP WITH YOUR APPLICATION? Visit www.medicaid.la.gov or call us at 1-888-342-6207. If you need help in a language other than
English, call 1-888-342-6207 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users
should call 1-800-220-5404.
American Indian or Alaska Native (AI/AN) Family Member(s)
Complete this appendix if you or any family members are American Indian or Alaska Native. Submit this with your Application
for Health Coverage.
Tell us about your American Indian or Alaska Native family member(s).
American Indians and Alaska Natives may not have to pay cost sharing and may get special monthly enrollment periods. Answer
the following questions to make sure your family gets the most help possible.
NOTE: If you have more people to include, make a copy of this page and attach.
AI/AN PERSON 1 AI/AN PERSON 2
1. Name
First Middle First Middle
Last Last
2. Member of a federally recognized tribe?
Yes
If yes, what is the tribe’s name?
No
Yes
If yes, what is the tribe’s name?
No
3.
Has this person ever gotten a service from the
Indian Health Service, a tribal health program,
or urban Indian health program, or through a
referral from one of these programs?
Yes
No
If no, is this person eligible to get
services from the Indian Health Service,
tribal health programs, or urban Indian
health programs, or through a referral
from one of these programs?
Yes 
No
Yes
No
If no, is this person eligible to get
services from the Indian Health Service,
tribal health programs, or urban Indian
health programs, or through a referral
from one of these programs?
Yes 
No
4.
Certain money received may not be counted.
List any income (amount and how often)
reported on your application that includes
money from these sources.
Check all that apply, and give the amount and
how often.
Per capita payments from a tribe that
come from natural resources, usage
rights, leases, or royalties
$ How often?
Payments from natural resources,
farming, ranching, shing, leases, or
royalties from land designated as
Indian trust land by the Department
of Interior (including reservations and
former reservations)
$ How often?
Money from selling things that have
cultural signicance
$ How often?
Per capita payments from a tribe that
come from natural resources, usage
rights, leases, or royalties
$ How often?
Payments from natural resources,
farming, ranching, shing, leases, or
royalties from land designated as Indian
trust land by the Department of Interior
(including reservations and former
reservations)
$ How often?
Money from selling things that have
cultural signicance
$ How often?
APPENDIX B
NEED HELP WITH YOUR APPLICATION? Visit www.medicaid.la.gov or call us at 1-888-342-6207. If you need help in a language other than
English, call 1-888-342-6207 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users
should call 1-800-220-5404.
Assistance with Completing this Application
For Medicaid Applicant or Enrollee: You can choose an authorized representative
You can give a trusted person permission to talk about your Medicaid eligibility with us, see your information, and act for you
on matters related to your application/renewal. This person is called an “authorized representative.” You are not required to
name any person or organization as your authorized representative. If you ever need to change your authorized representative,
contact Medicaid. If you are a legal representative of an applicant/enrollee, submit proof to Medicaid.
Select what you would like your authorized representative to be able to do (check all that apply):
Sign an application on your behalf.
Complete and submit a renewal form on your behalf.
Receive notices and other communications from Medicaid on your behalf. (If this option is selected, then all mail will be sent
to the authorized representative’s address only.)
Act on your behalf in all matters regarding your Medicaid case and receive information about your Medicaid case
1. Name of authorized representative (First, Middle, Last, & Suffix) or name of organization
2. Address 3. Apartment or suite number
4. City 5. State 6. ZIP code
7. Phone number
(
)
–
8. ID number (if applicable)
By signing below, I understand that I am designating the authorized representative listed above to perform the
actions that I have selected above. I understand that this will remain in effect until it is canceled.
I understand that all information gathered on my situation and those persons for whom I am legally responsible is personal
and confidential. My decision to appoint an authorized representative is optional, made freely, and does not relieve me of
my responsibility to actively participate in the Medicaid eligibility process. I understand that the function of the authorized
representative is to accompany, assist, and represent me in the eligibility determination process, and to aid in obtaining financial,
medical, and/or other documentation necessary for Medicaid to determine my eligibility for Medicaid. I understand that while
some of the information gathered may have no impact on my Medicaid eligibility, it may affect my liability to a third party if this
information is disclosed to the third party by my authorized representative. I hereby hold the Louisiana Department of Health
harmless for any claim resulting from disclosure of information to a third party by my authorized representative. I understand
that if this authorization is not signed in the presence of Medicaid staff, Medicaid staff may verify this designation.
9. Your name (First, Middle, Last, & Suffix)
10. Name of applicant/enrollee (First, Middle, Last, & Suffix) (if you are signing as their legal representative)
11. Your relationship to applicant/enrollee (if you are signing as their legal representative) 12. SSN or Case ID for applicant/enrollee
13. Your signature 14. Date (mm/dd/yyyy)
Continued on the following page...
APPENDIX C
NEED HELP WITH YOUR APPLICATION? Visit www.medicaid.la.gov or call us at 1-888-342-6207. If you need help in a language other than
English, call 1-888-342-6207 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users
should call 1-800-220-5404.
APPENDIX C (continued)
For the Authorized Representative
By signing below, the authorized representative agrees to: 1) Accept responsibility for fullling all responsibilities encompassed
within the scope of the authorized representation to the same extent as the individual represented; 2) Maintain, or be legally
bound to maintain, the condentiality of any information regarding the individual represented provided by the Louisiana
Department of Health; and 3) Adhere to the regulations in 42 CFR Part 431, Subpart F and at 45 CFR 155.260(f) (relating to the
condentiality of information), 42 CFR 447.10 (relating to the prohibition against reassignment of provider claims as appropriate
for a facility or an organization acting on the facility’s behalf), as well as other relevant state and federal laws concerning
conicts of interest and condentiality of information. If the authorized representative is an organization, this section must be
completed and signed by all individuals who will act on behalf of the organization and agree to be bound the conditions of this
agreement. By signing below, you certify under the penalty of perjury that any information provided on behalf of the individual
represented is true and correct to the best of your knowledge.
15. Name of authorized representative (First, Middle, Last, & Suffix) or name of organization 16. ID number (if applicable)
17. Name of individual acting on behalf of organization (First, Middle, Last, & Suffix) (if applicable)
18. Signature of Authorized representative or individual acting on behalf of organization 19. Date (mm/dd/yyyy)
Name of additional individual(s) who will act on behalf of the organization (if applicable):
20. Name of individual acting on behalf of organization (First, Middle, Last, & Suffix)
21. Signature of individual acting on behalf of organization 22. Date (mm/dd/yyyy)
23. Name of individual acting on behalf of organization (First, Middle, Last, & Suffix)
24. Signature of individual acting on behalf of organization 25. Date (mm/dd/yyyy)
26. Name of individual acting on behalf of organization (First, Middle, Last, & Suffix)
27. Signature of individual acting on behalf of organization 28. Date (mm/dd/yyyy)
29. Name of individual acting on behalf of organization (First, Middle, Last, & Suffix)
30. Signature of individual acting on behalf of organization 31. Date (mm/dd/yyyy)
NEED HELP WITH YOUR APPLICATION? Visit www.medicaid.la.gov or call us at 1-888-342-6207. If you need help in a language other than
English, call 1-888-342-6207 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users
should call 1-800-220-5404.
APPENDIX D
Personal Assets
(
optional
)
Complete this optional appendix if anyone applying has a physical, mental, or emotional health condition that causes limitations
in activities (like bathing, dressing, daily chores, etc.), lives in a medical facility or nursing home, or is 65 years of age or older.
DOES ANYONE IN
YOUR HOME OWN...
ASSET VALUE
(closest possible estimate)
DESCRIBE THIS ASSET
(include names of banks and other companies)
Checking accounts
Yes 
No
Who owns this?
$
Savings accounts
Yes 
No
Who owns this?
$
Vehicles
Yes 
No
Who owns this?
$
Property other than your home
Yes 
No
Who owns this?
$
Certificates of Deposit (CDs)
Yes 
No
Who owns this?
$
Annuities, Trusts, Stocks,
Bonds, or Retirement Accounts
Yes 
No
Who owns this?
$
Life or burial insurance.
Yes 
No
Who owns this?
$
Money set aside for
burial or pre-need contract
Yes 
No
Who owns this?
$
Safe deposit boxes
Yes 
No
Who owns this?
$
Other (Please describe in detail)
Yes 
No
Who owns this?
$
NEED HELP WITH YOUR APPLICATION? Visit www.medicaid.la.gov or call us at 1-888-342-6207. If you need help in a language other than
English, call 1-888-342-6207 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users
should call 1-800-220-5404.
APPENDIX E
Choosing a Health and Dental Plan
Most people on Medicaid or LaCHIP need to choose a Health Plan as well as a Dental Plan. These plans are groups of doctors,
nurses, dentists, and other sta who work together to provide health care. You can look at information about the dierent
Health and Dental Plans at www.healthy.la.gov. If you know which Health Plan or Dental Plan you want, please choose now. If
you do not choose, and you need to be in a Health or Dental Plan, we will choose for you.
Which Plan is Right for You?
All Health Plans must oer the same medical coverage, as well as all Dental Plans. Some of the plans oer extra benets. You
can choose a dierent Health Plan and Dental Plan for each person approved for full Medicaid.
Choosing a Plan
1. When choosing a plan the rst thing to consider is if your current provider is in that plan. Contact your doctors to nd out
what plans they accept.
2. For more information about the plans you can choose, visit www.healthy.la.gov or call 1-855-229-6848.
NOTE: If you chose a Health Plan or Dental Plan for anyone please include this appendix with your application.
I choose the following plans for each person applying:
NAME OF
PERSON APPLYING
SELECT A HEALTH AND DENTAL PLAN FOR THE PERSON APPLYING
(Please select only ONE Health Plan and ONE Dental Plan per person)
HEALTH PLANS
Aetna Better Health of Louisiana  AmeriHealth Caritas Louisiana  Healthy Blue
Louisiana Healthcare Connections  UnitedHealthcare Community Plan
DENTAL PLANS
DentaQuest  MCNA Dental
HEALTH PLANS
Aetna Better Health of Louisiana  AmeriHealth Caritas Louisiana  Healthy Blue
Louisiana Healthcare Connections  UnitedHealthcare Community Plan
DENTAL PLANS
DentaQuest  MCNA Dental
HEALTH PLANS
Aetna Better Health of Louisiana  AmeriHealth Caritas Louisiana  Healthy Blue
Louisiana Healthcare Connections  UnitedHealthcare Community Plan
DENTAL PLANS
DentaQuest  MCNA Dental
HEALTH PLANS
Aetna Better Health of Louisiana  AmeriHealth Caritas Louisiana  Healthy Blue
Louisiana Healthcare Connections  UnitedHealthcare Community Plan
DENTAL PLANS
DentaQuest  MCNA Dental
If you have more people to include, visit www.medicaid.la.gov to download and print additional pages
or make a copy of this page and complete.
THIS PAGE INTENTIONALLY
LEFT BLANK.
STATE OF LOUISIANA
VOTER REGISTRATION AGENCIES
DECLARATION FORM
If you are not registered to vote where you live now, would you like to apply
to register to vote here today? (Check one)
I want to register to vote. I do not want to register to vote.
IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE
DECIDED NOT TO REGISTER TO VOTE AT THIS TIME.
Applying to register or declining to register to vote will not affect the amount of assistance that you will be
provided by this agency. Voter eligibility requirements are found on the voter registration application form.
Note: If you do register to vote, the location where your application was submitted will remain confidential.
If you decline to register to vote, this fact will remain confidential. Applying to register or declining to
register to vote will be used only for voter registration purposes.
If you would like help in filling out the voter registration application form, we will help you. The
decision whether to seek or accept help is yours. You may fill out the application form in private.
(Check one)
Yes, I would like help. No, I do not want help.
For assistance in completing the voter registration application form outside our office, contact Louisiana
Department of Health and hospitals at 1-888-342-6207.
If completed outside our office, this declaration form and your completed voter registration application
form (if you filled one out) should be returned to P.O. Box 91278 Baton Rouge, LA 70821-9278.
Signature or Mark Name Typed or Printed Date
Signatures of Two Witnesses If Signed With Mark:
1) ____________________________________ 2) _______________________________________
COMPLAINTS
If you believe that someone has interfered with your right to register or to decline to register to vote, your
right to privacy in deciding whether to register or in applying to register to vote, or your right to choose
your own political party or other political preference, you may file a complaint with the Louisiana Secretary
of State, Commissioner of Elections, P.O. Box 94125, Baton Rouge, LA 70804-9125 or by calling (225)
922-0900 or 1-800-883-2805.
Comments/Remarks (for official use only):
NVRADF Rev. 6/14
THIS PAGE INTENTIONALLY
LEFT BLANK.
Louisiana Voter Registration Application
(LA-VRA - Rev. 6/19)
SEE THE OTHER SIDE OF THIS PAGE FOR INSTRUCTIONS
QUESTIONS? - Call your parish Registrar of Voters Office or call the
Secretary of State at 1-800-883-2805 or (225) 922-0900.
OFFICIAL USE ONLY:
Provided by the Louisiana Secretary of State
Approved by the Louisiana Attorney General
LA-VRA - Rev. 6/19
Please print clearly in ink, preferably black.
Reason for Application:
New Voter Registration
Updating Voter Registration
* If you do not have a LA driver’s license or LA special ID, the last four digits of your social security number are required if you have one. Full SSN is preferred but optional.
Note: If you decline to register to vote, this fact will remain confidential and will be used only for voter registration purposes. If you register to vote, the office where your application was submitted
will remain confidential and will be used only for voter registration purposes. You may request a copy of your voter registration form at any time from the registrar of voters.
Eligibility 1.
Are you a citizen of the United States of America?
Yes
No
If you checked ‘No’ in response to either of these questions, do not complete this form. You
are not eligible to vote at this time.
(Please see application instructions for information regarding eligibility to register
prior to age 18.)
Will you be 18 years of age on or before election day?
Yes
No
Name 2.
LAST NAME:
FIRST NAME:
FULL MIDDLE OR
MAIDEN NAME:
SUFFIX (Sr., Jr., II):
Residence
Address
(Where you live and
claim homestead
exemption, if any)
3.
HOUSE # &
STREET (NO P.O. BOX):
UNIT/APT #:
Give Location (If Necessary)
CITY/TOWN:
STATE
LA
ZIP CODE:
Mailing
Address
(If different from
Residence Address)
Check if no postal service at your residence address above and supply mailing address here.
HOUSE # &
STREET/P.O. BOX:
UNIT/APT #:
CITY/TOWN:
STATE:
ZIP CODE:
Date of Birth 4.
_______/_______/_________
MM DD YYYY
5.
*SSN
___________ - ________ - ____________
XXX XX XXXX
6.
Sex
M
F
7.
Race
(Optional)
WHITE BLACK ASIAN
HISPANIC AMERICAN INDIAN
OTHER ________________________
Party
Affiliation
8.
DEMOCRAT GREEN INDEPENDENT
LIBERTARIAN REPUBLICAN NO PARTY
OTHER
(Specify) ____________________________
9.
Place
of Birth
CITY/TOWN:
STATE:
PARISH/COUNTY:
COUNTRY:
Mother’s
Maiden Name
10.
____________________________
11.
Email
_______________________________
12.
Phone
Home: (________) _________ - ___________
Other: (________) _________ - ___________
LA DL/ID
Card #
13.
_________________________________________
I do not have a LA DL/ID card.
14.
Do you need
assistance in
voting?
No
Yes, Reason: _____________________________________________
Last
Residence
Address
15.
HOUSE #
& STREET:
16.
Place
of Last
Registration
STATE:
17.
Former
Registered
Name, if any
CITY:
STATE:
PARISH/
COUNTY:
Affirmation
and Signature
(Read and sign or
make your mark.)
18.
I do hereby solemnly swear or affirm that I am a United States citizen, that I am of eligible age to register to vote, that I have not been incarcerated pursuant to an order of
imprisonment for conviction of a felony within the past five years, nor am I under an order of imprisonment for a felony offense of election fraud or other election offense
pursuant to R.S. 18:1461.2, that I am not currently under a judgment of full interdiction or limited interdiction where my right to vote has been suspended, that I am a bona
fide resident of this state and parish, and that the facts given by me on this application are true to the best of my knowledge and belief. If I have provided false information,
I may be subject to a fine of not more than $2,000 ($5,000 for subsequent offense) or imprisonment for not more than 2 years (5 years for subsequent offense), or both.
Applicant
Signature:
Date:
Witnesses
(If your signature is
a mark, you must
have two witnesses
sign.)
19.
Witness #1
Signature:
Witness #1
Print Name:
Witness #2
Signature:
Witness #2
Print Name:
OFFICIAL USE ONLY
New Registration Updated Registration: Address Change Name Change Party Change Change to Assistance in Voting Other
REMARKS:
CIRCLE ONE:
PA MV RG SDA SS (Disability) Received by: __________________________________________________ Date: _________________________
Louisiana Voter Registration Application
(LA-VRA - Rev. 6/19)
QUESTIONS? - Call your parish Registrar of Voters Office or call
the Secretary of State at 1-800-883-2805 or (225) 922-0900.
Provided by the Louisiana Secretary of State
Approved by the Louisiana Attorney General
LA-VRA - Rev. 6/19
APPLICATION INSTRUCTIONS
USE THIS LOUISIANA VOTER REGISTRATION APPLICATION TO: 1) register to vote; 2) change your address; 3) request a name change; 4) change party affiliation; or
5) request assistance in voting.
TO REGISTER AND BE ELIGIBLE TO VOTE, AN APPLICANT MUST: 1) be a U.S. citizen; 2) be at least 17 years old (16 years old if registering to vote in person at the
Registrar’s Office or with an application for a Louisiana driver’s license) but must be 18 years old before actually voting; 3) not be under an order of imprisonment for
conviction of a felony or, if under such an order, not have been incarcerated pursuant to the order within the last five years and not be under an order of imprisonment related
to a felony conviction for election fraud or any other election offense pursuant to R.S. 18:1461.2; 4) not be under a judgment of full interdiction or limited interdiction where
your right to vote has been suspended; 5) reside in the state and parish in which you seek to register and vote.
Instructions: the gray section numbers on this page correspond to the gray section numbers on the application.
Reason for Application: Check “New Voter Registration” if this is a first time registration or if a new registration in a new parish after moving. Check “Updating Voter
Registration” if you are making any change to your present registration. If new registration, fill out the form completely.
1.
Eligibility - Federal law requires you to affirm that you are a citizen of the United States of America and that you will be 18 years of age on or before the election day in
which you are eligible to vote. If you checked ‘No’ in response to either of these questions, do not complete this form. You are not eligible to vote at this time. If you are
registering as a 16 or 17 year old, you may check “Yes” because you will not be allowed to vote until you are 18.
2.
Name - You must provide your full name. Do not use nicknames or initials for middle or maiden name. If this application is for a change of name, please also complete
section 17: “Former Registered Name.”
3.
Residence Address - “Residence Address” means the address (number, street, city, state, and zip) where you live and are registering to vote. Residence address must be
the address where you claim homestead exemption, if any, except for a resident in a nursing home or veterans’ home who may choose
to use the address of the nursing
home or veterans’ home or the home where they have a homestead exemption. A college student may elect to use their home address or their address at school
while
attending. Do not use a post office box for your “Residence Address.” If you use a rural route and box number, you may draw a map in box labeled “Give Location”
to
provide the exact location. Write in the names of the crossroads (streets) nearest to residence. Draw an X to show residence. Use a dot to show any scho
ols, churches,
stores, or landmarks near residence and write the name of the landmark.
Mailing Address - If you check that you do not receive postal service at your residence address, you must provide your mailing address (number, street, city, state, and
zip). Otherwise, a mailing address may be provided and you may use a post office box for a mailing address.
4.
Birthdate - Print your date of birth. The month and day of your birth remains confidential by law.
5.
Social Security Number - If you do not have a LA driver's license or LA special identification card, you must provide the last four digits of your social security number, if
issued. The full social security number is preferred and may be provided on a voluntary basis and will be kept confidential. If you were not issued a social security number
or a LA DL or ID and this form is submitted by mail, and you are registering to vote for the first time, in order to avoid additional identification requirements for first time
voters you must attach one or more documents to prove your identity, residence, and date of birth. Documents may be: a) a copy of current and valid photo identification
and/or b) a copy of a current utility bill, bank statement, government check, paycheck, or other government document.
Your SSN remains confidential and is only used for
registration purposes.
6.
Sex - Check male or female (for statistical purposes only).
7.
Race - Race/Ethnic origin is optional (for statistical purposes only).
8.
Party Affiliation - If you are registering for the first time, you may choose a party affiliation of Democrat, Green, Independent, Libertarian, or Republican parties. You may
specify any other party affiliation by checking “other” and then listing the party with which you wish to affiliate. If you do not want to register with a political par
ty affiliation
check “No Party,” or if you do not complete this section, your party affiliation will be listed as “No Party.” If you are already registered with a party affili
ation and no political
party change is being made with this application, you may leave this section blank or re-enter your political party affiliation.
9.
Place of Birth - Print the city/town, parish/county, state, and country of your birth place (for statistical purposes only).
10.
Mother’s Maiden Name - Print your mother’s maiden name, which is her last name at her birth. If unknown, write “unknown.”
11.
Email - Give your email address for election officials to contact you if there is a problem with your registration. Email addresses are protected from disclosure by law and
are for official use only.
12.
Phone - Give your phone numbers for election officials to contact you if there is a problem with your registration. Phone numbers are optional and a public record unless
you make a request for your phone numbers to be kept confidential by election officials.
13.
LA DL/ID Card # - Print your LA driver’s license or LA special identification card number, if issued. If you do not have one, check “I do not have a LA DL/ID card.” This ID
number remains confidential and is for official use only.
14.
Assistance in Voting Needed? - Indicate if you will need assistance in voting by checking either the “No” or “Yes” box. If “Yes,” write the reason for needing assistance. The
registrar of voters in your parish may contact you for proof of disability.
15.
Place of Last Residence - Print the address (number, street, city, and state) of your prior residence, if different from residence address in section 3 or write “Same.”
16.
Place of Last Registration - Print the state and parish (or county) of your last registration if you were registered in another parish or state prior to completing this
application. Important: Contact the local election office in your prior state and cancel your prior registration. Registering in Louisiana does not automatic
ally cancel or
transfer your voter registration from another state.
17.
Former Registered Name - If you are using this application to make a name change to your registration, print your former registered name (name you are changing) in this
section. If name changed by court order, provide a copy of the order with this application.
18.
Affirmation and Signature - Read the affirmation and sign your full name or make your mark and print the date this application was signed and completed. If assistance in
registering is being provided, make sure the applicant understands what they are affirming and that they meet the requirements to register to vote.
19.
Witnesses - If you are unable to sign your name, you may make your mark, but it must be witnessed by two people or it is not valid.
Mailing Instructions - If returned by mail, place in an envelope and mail to your Registrar of Voters Office. You can find your registrar of voters mailing address on the Registrar of
Voters Address Page, by visiting our website at www.geauxvote.com or by calling toll free at 1-800-883-2805. Your application or envelope must be postmarked 30 days prior to the first
election in which you seek to vote.
Online Voter Registration - Voter registration is also available at www.geauxvote.com and you may register online before the 20
th
day prior to the election. Please call your registrar of
voters if you do not receive your voter information card two weeks after registering.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Application for Health Coverage (State of Louisiana - Office of Technology Services)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 21 February 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document