Fillable Application for Health Insurance Your destination for affordable (Covered California)

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Application for Health Insurance Your destination for affordable (Covered California)

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health insurance, including Medi-Cal
Application for
Health Insurance
TM
Your destination for affordable
Covered California is the place where individuals and families can
get aordable health insurance. With just one application, you’ll nd out
if you qualify for free or low-cost health insurance, including Medi-Cal.
The state of California created Covered California™ to help you
and your family get health insurance.
Having health insurance can give you peace of mind and help make it
possible for you to stay healthy. With insurance, you’ll know you and your
family can get health care when you need it.
Use this application to see what insurance choices you qualify for:
Free or low-cost insurance from Medi-Cal
Low-cost insurance for pregnant women through Access for Infants
and Mothers (AIM)
Affordable private health insurance plans
Help paying for your health insurance
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.
You can use this application to apply for anyone in your family,
even if they already have insurance now.
Apply faster through Covered California
at CoveredCA.com
Or call: 1-800-300-1506 (TTY: 1-888-889-4500)
You can call Monday to Friday, 8 a.m. to 8 p.m.,
See Inside
Things to know
Application 2–19
Attachments A–F 20–28
Frequently Asked 29–33
Questions (FAQ)
You can get this
application in
other languages
Español 1-800-300-0213
1-800-300-1533
Tiếng Việt 1-800-652-9528
1-800-738-9116
Tagalog 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
Call 1-800-300-1506 to
get this application in
other formats, such as
large print.
and Saturday, 8 a.m. to 6 p.m.
STATE OF CALIFORNIA Health Insurance Application
(11/13)
|
CCFRM604
1
CCFRM604 (11/13) EN
Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). The call is free. You can call
Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.
Need help?
Things to know
What you need
to know when
you apply
Social Security numbers for applicants who are U.S. citizens, or document
information
for immigrants with satisfactory status who need insurance. Proof of citizenship or
immigration status is required only for applicants.
Employer and income information for everyone in your family.
Your federal tax information. For example, the person who files taxes as head of
household and the dependents claimed on your taxes.
Information about health insurance that you or any family member
gets through a job.
We ask about income and other information to make sure you and your family
get the most benefits possible.
We keep your information private and secure, as required by law.
We’ll use your information only to see if you qualify for health insurance.
Families that include immigrants can apply. You can apply for your child even if you
aren’t eligible for coverage. Applying for your eligible child won’t affect your immigration
status or chances of becoming a permanent resident or citizen.
If you don’t file taxes, you can still qualify for free or low-cost insurance through Medi-Cal.
If you are a federally recognized American Indian or Alaska Native who is getting
services from the Indian Health Services, tribal health programs, or urban Indian health
programs, you may still qualify for health insurance through Covered California.
Apply faster
Apply online at
CoveredCA.com. It's safe, secure, and fast
–
and you will get
results sooner!
online
When you’re
done
Send your completed and signed application to:
Covered California
P.O. Box 989725
West Sacramento, CA 95798-9725
If you don’t have all the information we ask for, sign and send in your application
anyway.
We can call you to help you finish your application.
Do not send your health insurance plan enrollment payment with this application.
Your plan will send you an invoice for the amount you owe.
Get help
with this
application
We're here to help you! You can get help at no cost.
Online: CoveredCA.com
Phone: Call our Customer Service Center at 1-800-300-1506 (TTY: 1-888-889-4500).
The call is free. You can call Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m.
In person: We have trained Certified Enrollment Counselors and Certified Insurance
Agents who can help you. For a list of Certified Enrollment Counselors and Certified
Insurance Agents near where you live or work, or a list of county social services offices
near you, visit CoveredCA.com or call 1-800-300-1506 (TTY: 1-888-889-4500).
This help is free!
If you have a disability or other need, we can provide assistance with completing this
application at no cost to you. You can go to your local county social services office in
person or call our Customer Service Center at 1-800-300-1506 (TTY: 1-888-889-4500).
1
CCFRM604 (11/13) EN
2
¿Preguntas?
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.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m.
O visite CoveredCA.com.
Start application here (use blue or black ink only)
Step 1:
Tell us about the adult who will be our main contact
for this application
First name Middle name Last name Suffix (examples: Sr., Jr., III, IV)
Home address Apartment #
City (home address) State ZIP code County
Check here if you do not have a home address. You must give us a mailing address below.
Check here if your mailing address is the same as your home address.
If it is not the same, you must give us your mailing address below:
Mailing address or P.O. box
(if dierent from home address)
Apartment #
City (mailing address) State ZIP code County
Best phone number to reach you
Home
Cell
Work
Number:
( ) –
Other phone number
Home
Cell
Work
Number:
( ) –
What language should we write to you in? What language do you want us to speak to you in?
How would you like to get information about this application?
Phone
Mail
Email Email address: ____________________________________________________________________________________________________________________________________
Are you applying for a child less than 1 year old?
Infants less than one year old are eligible for Medi-Cal if their mother was on Medi-Cal or AIM at the
time of delivery. You do not need to fill out an application to get Medi-Cal for an infant born to a
mother with Medi-Cal or AIM at the time of delivery. Call your county social services office when your
baby is born to make sure your baby is covered. Or fill out the information below.
Optional: If the following information is provided, the infant may be automatically eligible for Medi-Cal.
You do not have to fill out Step 2 of this application for the infant.
Are you applying for a child less than 1 year old?
Yes
No
If yes, did the child’s mother have Medi-Cal or AIM when the child was born?
Yes
No
If yes, will the child’s mother be listed on this application?
Yes
No
If yes, the mother is Person #
_____________________ on this application
If no, what is the mother’s first and last name? ______________________________________________________________________
Please provide the mother’s Medi-Cal number, AIM number, or SSN__________________________________________________________
CCFRM604 (11/13) EN
Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). The call is free. You can call
Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.
Need help?


Step 2:
Tell us about yourself and your family
Your income and family size help us decide what programs you qualify for. With this information, we
can make sure everyone gets the best coverage possible.
You must include these people on this application:
Your spouse
Your children who live with you
All parents living in the home with their child
Anyone on your federal income tax return, if you file one. You don’t need to file taxes to apply for
health insurance.
If you are claimed as a dependent on someone else's tax return, you must include all members of
the tax filing household that claimed you and any family members living with you.
Anyone else who lives with you
–
for example, a boyfriend, girlfriend, or roommate
–
will need to file
his or her own application if they want health insurance.
Complete Step 2 for each person in your family. Start with yourself!
To apply for more than four people on this application, make a copy of pages 6–8 for each
additional person.
We’ll keep all your information private, as required by law. We’ll use personal information only to
see if you qualify for health insurance. You do not need to provide the immigration status or Social
Security number (SSN) for those in your family who are not applying for health insurance.
Person 1 Tell us about yourself.
First name Middle name Last name Suffix (examples: Sr., Jr., III, IV) Relationship to you
Self
Are you:
Male
Female Are you:
Single
Never married
Married
Divorced
Registered domestic partner
Widowed
Date of birth
(month / day / year)
Are you pregnant?
Yes
No If yes, how many babies are expected? ____________
What is the expected delivery date?
______________________________________________________________________________________
Applying for health insurance Even if you have insurance now, you might find better coverage or lower costs.
Are you applying for health insurance for yourself?
Yes If yes, answer the questions below and complete pages 4 and 5.
No If you are not applying for yourself but you are applying for a dependent, be sure to fill in page 5.
No If you are not applying for yourself or for a dependent, go to page 6.
Social Security number (SSN)
___
–
__
–
____
If you do not have an SSN, what is the reason?
Adoption Taxpayer Identification Number (ATIN)
________________________________________________________
Individual Taxpayer Identification Number (ITIN)
_________________________________________________________
Religious exemption
I do not qualify for an SSN
You must provide a Social Security number (SSN) if you wish to apply for health insurance. We use Social
Security numbers (SSNs) to check income and other information. Even if you are not applying, giving your SSN
will help us review your application faster. Be sure to provide your SSN if you are not applying for yourself but
you file taxes and are applying for someone in your tax household.
If someone who is applying does not have an SSN and would like help getting one, call 1-800-300-1506
(TTY: 1-888-889-4500 ) or visit CoveredCA.com.
Person 1 continued on next page
3
CCFRM604 (11/13) EN
4
¿Preguntas?
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.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m.
O visite CoveredCA.com.
__________________________________
Step 2:
Person 1 (continued)
Federal income tax information If you don’t file taxes, you can still qualify for free or low-cost insurance through
Medi-Cal. We will keep your information private. We will use your information only to decide if you qualify for health insurance.
Are you the primary tax filer (your name was first on the tax return)?
Yes
No
Only one person on this application can be the primary tax filer.
Are you going to file taxes for the benefit year?
Yes
No
If yes, how will you file?
Head of household
Single
Married filing jointly
Married filing separately
Does anyone claim you as a dependent on their taxes?
Yes
No
If yes, who?
Person # ______________________ on this application
This person is a parent without custody
This person is a parent without custody who is not listed on this application
Do you have other health insurance or are you offered insurance through a job?
Yes
No
If yes, fill out Attachment B on pages 22 and 23.
Do you have a physical, mental, emotional, or developmental disability? Do you need help with long-term care or home
Yes
No See FAQ #27 for more information on what it means to have a disability.
and community-based services?
Yes
No
Are you a U.S. citizen or U.S. national?
Yes
No
If you are not a U.S. citizen or U.S. national, answer these questions:
Do you have satisfactory immigration status?
Yes To see if you have satisfactory status, go to Attachment E on page 27 for a list.
Then write the document information here. In most cases your document ID number will be your Alien Registration Number.
Document type: _________________________________________ ID number: ___________________________________________________________________________
Country of issuance: __________________________________________________________________ Expiration date: ___________________________________________________________________
Name as it appears on the document: ______________________________________________________________________________________________________________________________________
Have you lived in the U.S. since 1996? Are you, your spouse, or an unmarried dependent child an honorably discharged
Yes
No veteran or active-duty member of the U.S. armed forces?
Yes
No
Do you receive Medicare benefits? Did you have a medical expense in the last 3 months that you need help paying for?
Yes
No
Yes
No
Do you live with any children under the age of 19?
Yes
No
If yes, do you take care of the child or children?
Yes
No
Are you 18 to 20 years old and a full-time student?
Yes
No
Are you 18 to 26 years old?
Yes
No If yes,
were you in foster care in any state on your 18th birthday?
Yes
No
Are you 18 years old or younger?
Yes
No
How many parents live with you? ______________
Are you temporarily living out of state?
Yes
No
If you would like to choose a health insurance plan now, check here
and fill out Attachment D on page 25.
Tell us about your race
This information is confidential and will only be used to make sure that everyone has the
same access to health care. It will not be used to decide what health insurance you qualify for.
What is your race?
(optional;
check all that apply)
White
Asian Indian
Japanese
Guamanian or
Chamorro
Black or African
Cambodian
Korean
American
Samoan
Chinese
Laotian
American Indian
Other
Filipino
Vietnamese
or Alaska Native
Hmong
Native Hawaiian
Are you of Hispanic, Latino, or Spanish
origin?
(
optional)
Yes
No
If yes, check which ones:
Mexican, Mexican American, Chicano
Salvadoran
Guatemalan
Cuban
Puerto Rican
Other Hispanic, Latino, or Spanish
origin: ______________________________
Check here if you are an American Indian or Alaska Native, and fill out Attachment A on pages 20 and 21.
Person 1 continued on next page
CCFRM604 (11/13) EN
Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). The call is free. You can call
Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.
Need help?
Step 2:
Person 1 (continued)
Tell us about your current job and how you get money Attach an extra page if you need more space.
Do you work now?
Yes If yes, answer the questions below.
No If no, go to other income on this page.
Where do you work now? If you have more jobs, attach another sheet of paper.
JOB 1:
How do you get paid?
Hourly: How many hours per week?
Weekly
Every two weeks
Every six months
Yearly
__________
Daily: How many days per week?___________
Twice a month
Monthly
Quarterly
One-time payment (See FAQ #33 on page 33.)
Employer name (optional)
How much do you get paid (before taxes)? $ __________________________________
JOB 2:
How do you get paid?
Hourly: How many hours per week?
Weekly
Every two weeks
Every six months
Yearly
__________
Daily: How many days per week?___________
Twice a month
Monthly
Quarterly
One-time payment (See FAQ #33 on page 33.)
Employer name (optional)
How much do you get paid (before taxes)? $ __________________________________
Are you self-employed?
JOB 1:
Are you self-employed?
Yes If yes, answer the questions below.
No If no, go to other income on this page.
Type of work
How much net income will you get from self-employment this month?
$_______________________________________________________________
Net income means the profits left over after expenses are paid. Attachment E on page 27
lists what could be counted.
JOB 2:
Are you self-employed?
Yes If yes, answer the questions below.
No If no, go to other income on this page.
Type of work
How much net income will you get from self-employment this month?
$_______________________________________________________________
Net income means the profits left over after expenses are paid. Attachment E on page 27
lists what could be counted.
Do you have other income? Other income is money you get from something other than your job. Do not include child support
payments, veteran’s payments, or Supplemental Security Income (SSI). Go to Attachment E on page 27 to see examples of other income.
Do you have other income?
Yes If yes, answer the questions below.
No If no, go to income change on this page.
Where does this
income come from?
How often do you get paid? (check one) How much?
Hourly: How many hours per week?__________
Daily: How many days per week?___________
Weekly
Every two weeks
Twice a month
Monthly
Quarterly
Every six months
Yearly
One-time payment (See FAQ #33 on page 33.)
$
Hourly: How many hours per week?__________
Daily: How many days per week?___________
Weekly
Every two weeks
Twice a month
Monthly
Quarterly
Every six months
Yearly
One-time payment (See FAQ #33 on page 33.)
$
Does your income change from month to month? If it does, answer the two questions below.
What do you expect your total income to be this year?
(optional)
$_____________________________________________
If you expect your income to change next year, what will the
new total income be? (optional)
$___________________________________________
Do you have deductions? If you pay for certain things that can be deducted on a federal income tax return, telling us about them
may lower the cost of health insurance. Do not include self-employment expenses. Attachment E on page 27 lists other types of deductions.
Do you have deductions?
Yes If yes, answer the questions below.
No If no, go to the next page.
Type of deduction How often do you get or pay for this deduction? (check one) How much?
Alimony paid
Student loan interest
Other
Hourly: How many hours per week?__________
Daily: How many days per week?___________
Weekly
Every two weeks
Twice a month
Monthly
Quarterly
Every six months
Yearly
One-time payment (See FAQ #33 on page 33.)
$
Alimony paid
Student loan interest
Other
Hourly: How many hours per week?__________
Daily: How many days per week?___________
Weekly
Every two weeks
Twice a month
Monthly
Quarterly
Every six months
Yearly
One-time payment (See FAQ #33 on page 33.)
$
5
CCFRM604 (11/13) EN
6
¿Preguntas?
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.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m.
O visite CoveredCA.com.
Person 2 Tell us about the next person living in your home.
Step 2:
If you have more than four people on this application, make a copy of pages 6–8 for
each additional person.
First name Middle name Last name Suffix (examples: Sr., Jr., III, IV) Relationship to you
Check here if this person's home address is the same as the main contact's home address.
If it is not the same, you must give us this person's home address below:
Home address Apartment #
City (home address)
State ZIP code County
Check here if this person does not have a home address. You must give us a mailing address below.
Check here if this person's mailing address is the same as the main contact's mailing address.
If it is not the same, you must give us this person's mailing address below:
Mailing address or P.O. box
(if dierent from home address)
Apartment #
City (mailing address)
State ZIP code County
Best phone number to reach this person
Home
Number:
( )
–
Cell
Work Other phone number
Home
Number:
( )
–
Cell
Work
Email address:
What language should we write to this person in? What language does this person want us to speak to him or her in?
Is this person:
Male
Female Is this person:
Single
Never married
Married
Divorced
Registered domestic partner
Widowed
Date of birth
(month / day / year)
Is this person pregnant?
Yes
No If yes, how many babies are expected?_____________
What is the expected delivery date?
_________________________________________________________________________________________
Applying for health insurance Even if this person has insurance now, you might find better coverage or lower costs.
Is this person applying for health insurance?
Yes If yes, answer the questions below.
No If no, SSN information is optional.
Social Security number (SSN)
___
–
__
–
____
If this person does not have an SSN, what is the reason?
Adoption Taxpayer Identification Number (ATIN)
________________________________________________________
Individual Taxpayer Identification Number (ITIN)
_________________________________________________________
Religious exemption
Does not qualify for an SSN
Federal income tax information If this person didn’t file taxes, he or she can still qualify for free or low-cost insurance
through Medi-Cal. We will keep the information private and use it only to decide if the person qualifies for health insurance.
Is this person the primary tax filer (his or her name was first on the tax return)?
Yes
No
Only one person on this application can be the primary tax filer.
Is this person going to file taxes for the benefit year?
Yes
No If yes, how will he or she file?
Head of household
Single
Dependent
Married filing jointly
Married filing separately
Does anyone claim this person as a dependent on their taxes?
Yes
No
If yes, who?
Person # ______________________ on this application
This person is a parent without custody
This person is a parent without custody who is not listed on this application
Person 2 continued on next page
CCFRM604 (11/13) EN
Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). The call is free. You can call
Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.
Need help?
____________________________
Step 2:
Person 2 (continued)
Does this person have other health insurance or is this person offered insurance through a job?
Yes
No
If yes, fill out Attachment B on pages 22 and 23.
Does this person have a physical, mental, emotional, or
developmental disability?
Yes
No
See FAQ #27 for more information on what it means to have a disability.
Does this person need help with long-term care or
home and community-based services?
Yes
No
Is this person a U.S. citizen or U.S. national?
Yes
No
If this person is not a U.S. citizen or
U.S.
national, answer these questions:
Does this person have satisfactory immigration status?
Yes To see if this person has satisfactory status, go to Attachment E on page 27.
for a list. Then write the document information here. In most cases the document ID number will be the Alien Registration Number.
Document type: __________________________________________________________________________ ID number: __________________________________________________________________________
Country of issuance: ___________________________________________________________________ Expiration date: __________________________________________________________________
Name as it appears on the document: ______________________________________________________________________________________________________________________________________
Has this person lived in the U.S. since 1996?
Yes
No
Is this person, this person's spouse, or an unmarried dependent child an honorably discharged veteran
or active-duty member of the U.S. armed forces?
Yes
No
Does
this person
receive Medicare benefits? Did
this person
have a medical expense in the last 3 months that he or she
Yes
No
needs help paying for?
Yes
No
Does this person live with any children under the age of 19?
Yes
No
If yes, does this person take care of the child or children?
Yes
No
Is this person 18 to 20 years old and a full-time student?
Yes
No
Is this person 18 to 26 years old?
Yes
No
If yes,
was this person in foster care in any state on his or her 18th birthday?
Yes
No
Is this person 18 years old or younger?
Yes
No
How many parents live with this person? _________________
Is this person temporarily living out of state?
Yes
No
Tell us about this person’s race
This information is confidential and will only be used to make sure that everyone
has the same access to health care. It will not be used to decide what health insurance you qualify for.
What is this person's race?
(optional; c
heck all that apply)
White
Asian Indian
Japanese
Guamanian or
Chamorro
Black or African
Cambodian
Korean
American
Samoan
Chinese
Laotian
American Indian
Other
Filipino
Vietnamese
or Alaska Native
Hmong
Native Hawaiian
Is this person of Hispanic, Latino, or
Spanish origin?
(
optional)
Yes
No
If yes, check which ones:
Mexican, Mexican American, Chicano
Salvadoran
Guatemalan
Cuban
Puerto Rican
Other Hispanic, Latino, or Spanish
origin: ______________________________
Check here if this person is an American Indian or Alaska Native, and fill out Attachment A on pages 20 and 21.
Person 2 continued on next page
7
CCFRM604 (11/13) EN
8
¿Preguntas?
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.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m.
O visite CoveredCA.com.
Step 2:
Person 2 (continued)
Tell us about this person's current job and how he or she gets money Attach an extra page if you need more space.
Does this person work now?
Yes If yes, answer the questions below.
No If no, go to other income on this page.
Where does this person work now? If he or she has more jobs, attach another sheet of paper.
JOB 1:
How does this
person get paid?
Hourly: How many hours per week?__________
Daily: How many days per week?___________
Weekly
Every two weeks
Twice a month
Monthly
Quarterly
Every six months
Yearly
One-time payment (See FAQ #33 on page 33.)
Employer name (optional)
How much does this person get paid (before taxes)? $ __________________
JOB 2:
How does this
person get paid?
Hourly: How many hours per week?__________
Daily: How many days per week?___________
Weekly
Every two weeks
Twice a month
Monthly
Quarterly
Every six months
Yearly
One-time payment (See FAQ #33 on page 33.)
Employer name (optional)
How much does this person get paid (before taxes)? $ __________________
Is this person self-employed?
JOB 1:
Is this person self-employed?
Yes If yes, answer the questions below.
No If no, go to other income on this page.
Type of work
How much net income will this person get from self-employment this month?
$___________________________________________________
Net income means the profits left over after expenses are paid. Attachment E on page 27
lists what could be counted.
JOB 2:
Is this person self-employed?
Yes If yes, answer the questions below.
No If no, go to other income on this page.
Type of work
How much net income will this person get from self-employment this month?
$___________________________________________________
Net income means the profits left over after expenses are paid. Attachment E on page 27
lists what could be counted.
Does this person have other income? Other income is money you get from something other than your job. Go to Attachment E on
page 27 to see examples of other income. Do not include child support payments, veteran’s payments, or Supplemental Security Income (SSI).
Does this person have other income?
Yes If yes, answer the questions below.
No If no, go to income change on this page.
Where does this
income come from?
How often does this person get paid? (check one) How much?
Hourly: How many hours per week?__________
Daily: How many days per week?___________
Weekly
Every two weeks
Twice a month
Monthly
Quarterly
Every six months
Yearly
One-time payment (See FAQ #33 on page 33.)
$
Hourly: How many hours per week?__________
Daily: How many days per week?___________
Weekly
Every two weeks
Twice a month
Monthly
Quarterly
Every six months
Yearly
One-time payment (See FAQ #33 on page 33.)
$
Does this person's income change from month to month? If it does, answer the two questions below.
What does this person expect this person's total income to be
this year? (optional)
$____________________________________
If you expect this person's income to change next year, what
will the new total income be? (optional)
$ ______________________________
Does this person have deductions? If this person pays for certain things that can be deducted on a federal income tax return, telling us
about them may lower the cost of health insurance. Do not include self-employment expenses. Attachment E on page 27 lists other types of deductions.
Does this person have deductions?
Yes If yes, answer the questions below.
No If no, go to the next page.
Type of deduction How often does this person get or pay for this deduction? (check one) How much?
Alimony paid
Student loan interest
Other
Hourly: How many hours per week?__________
Daily: How many days per week?___________
Weekly
Every two weeks
Twice a month
Monthly
Quarterly
Every six months
Yearly
One-time payment (See FAQ #33 on page 33.)
$
Alimony paid
Student loan interest
Other
Hourly: How many hours per week?__________
Daily: How many days per week?___________
Weekly
Every two weeks
Twice a month
Monthly
Quarterly
Every six months
Yearly
One-time payment (See FAQ #33 on page 33.)
$
CCFRM604 (11/13) EN
Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). The call is free. You can call
Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.
Need help?
Step 2:
Person 3 Tell us about the next person living in your home.
First name Middle name Last name Suffix (examples: Sr., Jr., III, IV) Relationship to you
Check here if this person's home address is the same as the main contact's home address.
If it is not the same, you must give us this person's home address below:
Home address Apartment #
City (home address)
State ZIP code County
Check here if this person does not have a home address. You must give us a mailing address below.
Check here if this person's mailing address is the same as the main contact's mailing address.
If it is not the same, you must give us this person's mailing address below:
Mailing address or P.O. box
(if dierent from home address)
Apartment #
City (mailing address)
State ZIP code County
Best phone number to reach this person
Home
Number:
( )
–
Cell
Work Other phone number
Home
Number:
( )
–
Cell
Work
Email address:
What language should we write to this person in?
What language does this person want us to speak to him or her in?
Is this person:
Male
Female Is this person:
Single
Never married
Married
Divorced
Registered domestic partner
Widowed
Date of birth
(month / day / year)
Is this person pregnant?
Yes
No If yes, how many babies are expected?_____________
What is the expected delivery date?
_________________________________________________________________________________________
Applying for health insurance Even if this person has insurance now, you might find better coverage or lower costs.
Is this person applying for health insurance?
Yes If yes, answer the questions below.
No If no, SSN information is optional.
Social Security number (SSN)
___
–
__
–
____
If this person does not have an SSN, what is the reason?
Adoption Taxpayer Identification Number (ATIN)
________________________________________________________
Individual Taxpayer Identification Number (ITIN)
_________________________________________________________
Religious exemption
Does not qualify for an SSN
Federal income tax information If this person didn’t file taxes, he or she can still qualify for free or low-cost insurance
through Medi-Cal. We will keep the information private and use it only to decide if the person qualifies for health insurance.
Is this person the primary tax filer (his or her name was first on the tax return)?
Yes
No
Only one person on this application can be the primary tax filer.
Is this person going to file taxes for the benefit year?
Yes
No If yes, how will he or she file?
Head of household
Single
Dependent
Married filing jointly
Married filing separately
Does anyone claim this person as a dependent on their taxes?
Yes
No
If yes, who?
Person # ______________________ on this application
This person is a parent without custody
This person is a parent without custody who is not listed on this application
Person 3 continued on next page
9
CCFRM604 (11/13) EN
10
¿Preguntas?
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.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m.
O visite CoveredCA.com.
____________________________
Step 2:
Person 3 (continued)
Does this person have other health insurance or is this person offered insurance through a job?
Yes
No
If yes, fill out Attachment B on pages 22 and 23.
Does this person have a physical, mental, emotional, or
developmental disability?
Yes
No
See FAQ #27 for more information on what it means to have a disability.
Does this person need help with long-term care or
home and community-based services?
Yes
No
Is this person a U.S. citizen or U.S. national?
Yes
No
If this person is not a U.S. citizen or
U.S.
national, answer these questions:
Does this person have satisfactory immigration status?
Yes To see if this person has satisfactory status, go to Attachment E on page 27.
for a list. Then write the document information here. In most cases the document ID number will be the Alien Registration Number.
Document type: __________________________________________________________________________ ID number: __________________________________________________________________________
Country of issuance: ___________________________________________________________________ Expiration date: __________________________________________________________________
Name as it appears on the document: ______________________________________________________________________________________________________________________________________
Has this person lived in the U.S. since 1996?
Yes
No
Is this person, this person's spouse, or an unmarried dependent child an honorably discharged veteran
or active-duty member of the U.S. armed forces?
Yes
No
Does
this person
receive Medicare benefits? Did
this person
have a medical expense in the last 3 months that he or she
Yes
No
needs help paying for?
Yes
No
Does this person live with any children under the age of 19?
Yes
No
If yes, does this person take care of the child or children?
Yes
No
Is this person 18 to 20 years old and a full-time student?
Yes
No
Is this person 18 to 26 years old?
Yes
No
If yes,
was this person in foster care in any state on his or her 18th birthday?
Yes
No
Is this person 18 years old or younger?
Yes
No
How many parents live with this person? _________________
Is this person temporarily living out of state?
Yes
No
Tell us about this person’s race
This information is confidential and will only be used to make sure that everyone
has the same access to health care. It will not be used to decide what health insurance you qualify for.
What is this person's race?
(optional; c
heck all that apply)
White
Asian Indian
Japanese
Guamanian or
Chamorro
Black or African
Cambodian
Korean
American
Samoan
Chinese
Laotian
American Indian
Other
Filipino
Vietnamese
or Alaska Native
Hmong
Native Hawaiian
Is this person of Hispanic, Latino, or
Spanish origin?
(
optional)
Yes
No
If yes, check which ones:
Mexican, Mexican American, Chicano
Salvadoran
Guatemalan
Cuban
Puerto Rican
Other Hispanic, Latino, or Spanish
origin: ______________________________
Check here if this person is an American Indian or Alaska Native, and fill out Attachment A on pages 20 and 21.
Person 3 continued on next page
CCFRM604 (11/13) EN
Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). The call is free. You can call
Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.
Need help?
Step 2:
Person 3 (continued)
Tell us about this person's current job and how he or she gets money Attach an extra page if you need more space.
Does this person work now?
Yes If yes, answer the questions below.
No If no, go to other income on this page.
Where does this person work now? If he or she has more jobs, attach another sheet of paper.
JOB 1:
How does this
person get paid?
Hourly: How many hours per week?__________
Daily: How many days per week?___________
Weekly
Every two weeks
Twice a month
Monthly
Quarterly
Every six months
Yearly
One-time payment (See FAQ #33 on page 33.)
Employer name (optional)
How much does this person get paid (before taxes)? $ __________________
JOB 2:
How does this
person get paid?
Hourly: How many hours per week?__________
Daily: How many days per week?___________
Weekly
Every two weeks
Twice a month
Monthly
Quarterly
Every six months
Yearly
One-time payment (See FAQ #33 on page 33.)
Employer name (optional)
How much does this person get paid (before taxes)? $ __________________
Is this person self-employed?
JOB 1:
Is this person self-employed?
Yes If yes, answer the questions below.
No If no, go to other income on this page.
Type of work
How much net income will this person get from self-employment this month?
$___________________________________________________
Net income means the profits left over after expenses are paid. Attachment E on page 27
lists what could be counted.
JOB 2:
Is this person self-employed?
Yes If yes, answer the questions below.
No If no, go to other income on this page.
Type of work
How much net income will this person get from self-employment this month?
$___________________________________________________
Net income means the profits left over after expenses are paid. Attachment E on page 27
lists what could be counted.
Does this person have other income? Other income is money you get from something other than your job. Go to Attachment E on
page 27 to see examples of other income. Do not include child support payments, veteran’s payments, or Supplemental Security Income (SSI).
Does this person have other income?
Yes If yes, answer the questions below.
No If no, go to income change on this page.
Where does this
income come from?
How often does this person get paid? (check one) How much?
Hourly: How many hours per week?__________
Daily: How many days per week?___________
Weekly
Every two weeks
Twice a month
Monthly
Quarterly
Every six months
Yearly
One-time payment (See FAQ #33 on page 33.)
$
Hourly: How many hours per week?__________
Daily: How many days per week?___________
Weekly
Every two weeks
Twice a month
Monthly
Quarterly
Every six months
Yearly
One-time payment (See FAQ #33 on page 33.)
$
Does this person's income change from month to month? If it does, answer the two questions below.
What does this person expect this person's total income to be
this year? (optional)
$____________________________________
If you expect this person's income to change next year, what
will the new total income be? (optional)
$ ______________________________
Does this person have deductions? If this person pays for certain things that can be deducted on a federal income tax return, telling us
about them may lower the cost of health insurance. Do not include self-employment expenses. Attachment E on page 27 lists other types of deductions.
Does this person have deductions?
Yes If yes, answer the questions below.
No If no, go to the next page.
Type of deduction How often does this person get or pay for this deduction? (check one) How much?
Alimony paid
Student loan interest
Other
Hourly: How many hours per week?__________
Daily: How many days per week?___________
Weekly
Every two weeks
Twice a month
Monthly
Quarterly
Every six months
Yearly
One-time payment (See FAQ #33 on page 33.)
$
Alimony paid
Student loan interest
Other
Hourly: How many hours per week?__________
Daily: How many days per week?___________
Weekly
Every two weeks
Twice a month
Monthly
Quarterly
Every six months
Yearly
One-time payment (See FAQ #33 on page 33.)
$
11
CCFRM604 (11/13) EN
12
¿Preguntas?
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.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m.
O visite CoveredCA.com.
Step 2:
Person 4 Tell us about the next person living in your home.
First name Middle name Last name Suffix (examples: Sr., Jr., III, IV) Relationship to you
Check here if this person's home address is the same as the main contact's home address.
If it is not the same, you must give us this person's home address below:
Home address Apartment #
City (home address)
State ZIP code County
Check here if this person does not have a home address. You must give us a mailing address below.
Check here if this person's mailing address is the same as the main contact's mailing address.
If it is not the same, you must give us this person's mailing address below:
Mailing address or P.O. box
(if dierent from home address)
Apartment #
City (mailing address)
State ZIP code County
Best phone number to reach this person
Home
Number:
( )
–
Cell
Work Other phone number
Home
Number:
( )
–
Cell
Work
Email address:
What language should we write to this person in?
What language does this person want us to speak to him or her in?
Is this person:
Male
Female Is this person:
Single
Never married
Married
Divorced
Registered domestic partner
Widowed
Date of birth
(month / day / year)
Is this person pregnant?
Yes
No If yes, how many babies are expected?_____________
What is the expected delivery date?
_________________________________________________________________________________________
Applying for health insurance Even if this person has insurance now, you might find better coverage or lower costs.
Is this person applying for health insurance?
Yes If yes, answer the questions below.
No If no, SSN information is optional.
Social Security number (SSN)
___
–
__
–
____
If this person does not have an SSN, what is the reason?
Adoption Taxpayer Identification Number (ATIN)
________________________________________________________
Individual Taxpayer Identification Number (ITIN)
_________________________________________________________
Religious exemption
Does not qualify for an SSN
Federal income tax information If this person didn’t file taxes, he or she can still qualify for free or low-cost insurance
through Medi-Cal. We will keep the information private and use it only to decide if the person qualifies for health insurance.
Is this person the primary tax filer (his or her name was first on the tax return)?
Yes
No
Only one person on this application can be the primary tax filer.
Is this person going to file taxes for the benefit year?
Yes
No If yes, how will he or she file?
Head of household
Single
Dependent
Married filing jointly
Married filing separately
Does anyone claim this person as a dependent on their taxes?
Yes
No
If yes, who?
Person # ______________________ on this application
This person is a parent without custody
This person is a parent without custody who is not listed on this application
Person 4 continued on next page
CCFRM604 (11/13) EN
Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). The call is free. You can call
Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.
Need help?
____________________________
Step 2:
Person 4 (continued)
Does this person have other health insurance or is this person offered insurance through a job?
Yes
No
If yes, fill out Attachment B on pages 22 and 23.
Does this person have a physical, mental, emotional, or
developmental disability?
Yes
No
See FAQ #27 for more information on what it means to have a disability.
Does this person need help with long-term care or
home and community-based services?
Yes
No
Is this person a U.S. citizen or U.S. national?
Yes
No
If this person is not a U.S. citizen or
U.S.
national, answer these questions:
Does this person have satisfactory immigration status?
Yes To see if this person has satisfactory status, go to Attachment E on page 27.
for a list. Then write the document information here. In most cases the document ID number will be the Alien Registration Number.
Document type: __________________________________________________________________________ ID number: __________________________________________________________________________
Country of issuance: ___________________________________________________________________ Expiration date: __________________________________________________________________
Name as it appears on the document: ______________________________________________________________________________________________________________________________________
Has this person lived in the U.S. since 1996?
Yes
No
Is this person, this person's spouse, or an unmarried dependent child an honorably discharged veteran
or active-duty member of the U.S. armed forces?
Yes
No
Does
this person
receive Medicare benefits? Did
this person
have a medical expense in the last 3 months that he or she
Yes
No
needs help paying for?
Yes
No
Does this person live with any children under the age of 19?
Yes
No
If yes, does this person take care of the child or children?
Yes
No
Is this person 18 to 20 years old and a full-time student?
Yes
No
Is this person 18 to 26 years old?
Yes
No
If yes,
was this person in foster care in any state on his or her 18th birthday?
Yes
No
Is this person 18 years old or younger?
Yes
No
How many parents live with this person? _________________
Is this person temporarily living out of state?
Yes
No
Tell us about this person’s race
This information is confidential and will only be used to make sure that everyone
has the same access to health care. It will not be used to decide what health insurance you qualify for.
What is this person's race?
(optional; c
heck all that apply)
White
Asian Indian
Japanese
Guamanian or
Chamorro
Black or African
Cambodian
Korean
American
Samoan
Chinese
Laotian
American Indian
Other
Filipino
Vietnamese
or Alaska Native
Hmong
Native Hawaiian
Is this person of Hispanic, Latino, or
Spanish origin?
(
optional)
Yes
No
If yes, check which ones:
Mexican, Mexican American, Chicano
Salvadoran
Guatemalan
Cuban
Puerto Rican
Other Hispanic, Latino, or Spanish
origin: ______________________________
Check here if this person is an American Indian or Alaska Native, and fill out Attachment A on pages 20 and 21.
Person 4 continued on next page
13
CCFRM604 (11/13) EN
14
¿Preguntas?
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.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m.
O visite CoveredCA.com.
Step 2:
Person 4 (continued)
Tell us about this person's current job and how he or she gets money Attach an extra page if you need more space.
Does this person work now?
Yes If yes, answer the questions below.
No If no, go to other income on this page.
Where does this person work now? If he or she has more jobs, attach another sheet of paper.
JOB 1:
How does this
person get paid?
Hourly: How many hours per week?__________
Daily: How many days per week?___________
Weekly
Every two weeks
Twice a month
Monthly
Quarterly
Every six months
Yearly
One-time payment (See FAQ #33 on page 33.)
Employer name (optional)
How much does this person get paid (before taxes)? $ __________________
JOB 2:
How does this
person get paid?
Hourly: How many hours per week?__________
Daily: How many days per week?___________
Weekly
Every two weeks
Twice a month
Monthly
Quarterly
Every six months
Yearly
One-time payment (See FAQ #33 on page 33.)
Employer name (optional)
How much does this person get paid (before taxes)? $ __________________
Is this person self-employed?
JOB 1:
Is this person self-employed?
Yes If yes, answer the questions below.
No If no, go to other income on this page.
Type of work
How much net income will this person get from self-employment this month?
$___________________________________________________
Net income means the profits left over after expenses are paid. Attachment E on page 27
lists what could be counted.
JOB 2:
Is this person self-employed?
Yes If yes, answer the questions below.
No If no, go to other income on this page.
Type of work
How much net income will this person get from self-employment this month?
$___________________________________________________
Net income means the profits left over after expenses are paid. Attachment E on page 27
lists what could be counted.
Does this person have other income? Other income is money you get from something other than your job. Go to Attachment E on
page 27 to see examples of other income. Do not include child support payments, veteran’s payments, or Supplemental Security Income (SSI).
Does this person have other income?
Yes If yes, answer the questions below.
No If no, go to income change on this page.
Where does this
income come from?
How often does this person get paid? (check one) How much?
Hourly: How many hours per week?__________
Daily: How many days per week?___________
Weekly
Every two weeks
Twice a month
Monthly
Quarterly
Every six months
Yearly
One-time payment (See FAQ #33 on page 33.)
$
Hourly: How many hours per week?__________
Daily: How many days per week?___________
Weekly
Every two weeks
Twice a month
Monthly
Quarterly
Every six months
Yearly
One-time payment (See FAQ #33 on page 33.)
$
Does this person's income change from month to month? If it does, answer the two questions below.
What does this person expect this person's total income to be
this year? (optional)
$____________________________________
If you expect this person's income to change next year, what
will the new total income be? (optional)
$ ______________________________
Does this person have deductions? If this person pays for certain things that can be deducted on a federal income tax return, telling us
about them may lower the cost of health insurance. Do not include self-employment expenses. Attachment E on page 27 lists other types of deductions.
Does this person have deductions?
Yes If yes, answer the questions below.
No If no, go to the next page.
Type of deduction How often does this person get or pay for this deduction? (check one) How much?
Alimony paid
Student loan interest
Other
Hourly: How many hours per week?__________
Daily: How many days per week?___________
Weekly
Every two weeks
Twice a month
Monthly
Quarterly
Every six months
Yearly
One-time payment (See FAQ #33 on page 33.)
$
Alimony paid
Student loan interest
Other
Hourly: How many hours per week?__________
Daily: How many days per week?___________
Weekly
Every two weeks
Twice a month
Monthly
Quarterly
Every six months
Yearly
One-time payment (See FAQ #33 on page 33.)
$
CCFRM604 (11/13) EN
Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). The call is free. You can call
Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.
Need help?
Step 3:
Please read and sign this application
You can choose an authorized representative

You can choose someone to be your “authorized representative.” An authorized representative is a person
you allow to see your application and talk with us about it now and in the future.
Name of authorized representative
Address Apartment #
City State ZIP code County
By signing, you allow this person to sign your application, to get official information about this application,
and to act for you on all future matters with this agency.
Your signature
Date
Privacy statement
This application is for health insurance through Covered
California or for benefits through the Department of Health
Care Services (DHCS). The personal and medical information
you provide on it is private and confidential. Covered
California or the DHCS needs it to identify you and the other
people on this application and to administer our programs.
We will share your information with other state, federal, and
local agencies, contractors, health plans, and programs only
to enroll you in a plan or program or to administer programs,
and with other state and federal agencies as required by law.
You must answer all of the questions on this application
unless they are marked “optional.” If your application
is missing anything that we require, we will contact you
to get it.
If you do not provide it, we will not be able
to make a decision on your application. You may have
to submit a new application, or you may not be able to
get health insurance through Covered California, or your
application for benefits may be denied.
In most cases, you have the right to see personal
information about you that is in federal and state records.
You can see it in an alternative format (such as large print)
if you need that.
For more information or to see Covered California records,
contact the Privacy Officer at:
Covered California
Attn: Privacy Officer
P.O. Box 989725
West Sacramento, CA 95798-9725
Phone: 1-800-300-1506
TTY: 1-888-889-4500
For the Department of Health Care Services, contact the
Information Protection Unit at:
P.O. Box 997413, MS 4721
Sacramento, CA
95899-7413
Phone: 1-866-866-0602
TTY: 1-877-735-2929
These state and federal laws give us the right to collect and keep the
information on the application:
Covered CA: 42 U.S.C. § 18031; CA Government Code §§ 100502(k) and
100503(a)
DHCS: CA Welfare and Institutions. Code § 14011 and Article 3, Chapters 5
and 7, Parts 2 and 3, Division 9
We must give you this Privacy Statement under CA Civil Code § 1798.17.
You can see Covered California's Privacy Policy at
CoveredCA.com. See DHCS's Notice of Privacy Practices at dhcs.ca.gov.
Step 3 continued on next page
15
CCFRM604 (11/13) EN
16
¿Preguntas?
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.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m.
O visite CoveredCA.com.
Step 3:
Please read and sign this application (continued)
Your rights and responsibilities
The information I gave on this application is true as far as
I know. I know that I may be subject to a penalty if I do not
tell the truth.
I understand that the information I give will be used only
to see if those in my family who are applying for health
insurance will qualify.
I understand that Covered California and the Medi-Cal
program will keep my information private, as the law
requires. For more information, or access to personal
information in records maintained by Covered California
and the Medi-Cal program, I can contact the Privacy Officer
at 1-800-300-1506 (TTY: 1-888-889-4500).
I understand that to be eligible for Medi-Cal, I am required
to apply for other income or benefits to which I or any
member of my household is entitled, unless he or she has
good cause for not doing so. Examples of such income or
benefits are pensions, government benefits, retirement
income, veteran's benefits, annuities, disability benefits,
Social Security benefits (also called OASDI or Old Age,
Survivors, and Disability Insurance), and unemployment
benefits. But such income or benefits do not include public
assistance benefits, such as CalWORKs or CalFresh. If I have
a question about a possible source of income, I can call
Covered California at 1-800-300-1506 (TTY: 1-888-889-4500)
for help.
I know that I must tell Covered California or my county
social services office about changes to anything I wrote
on this application. To report changes, I can call Covered
California at 1-800-300-1506 (TTY: 1-888-889-4500) or visit
CoveredCA.com. Or I can call my county social services
office.
I know that Covered California must not discriminate against
me or anyone on this application because of race, color,
national origin, religion, age, sex, sexual orientation, marital
status, veteran’s status, or disability. If I think Covered
California has discriminated against me, including the
failure to provide reasonable accommodations as required
under state and federal law, I can make a complaint by
visiting www.hhs.gov/ocr/office/file or http://oag.ca.gov/
contact/general-comment-question-or-complaint-form. If
I believe that Covered California has discriminated against
me or anyone else on this application in connection with a
Medi-Cal eligibility determination, I can also file a complaint
with the Department of Health Care Services, Office of Civil
Rights by calling 1-916-440-7370 (TTY: 1-916-440-7399).
I understand that any changes in my information or
information of any member(s) in the applicant’s household
may affect the eligibility of other members of the
household.
Except for purposes of applying for Medi-Cal, I confirm
that no one applying for health insurance on this
application is confined, after the disposition of charges
(judgment), in a jail, prison, or similar penal institution or
correctional facility.
I understand that I must report income changes to
Covered California because it may affect the amount
of premium assistance (or tax credits) that I may be
eligible to receive. I also understand if I receive too much
premium assistance (or tax credits) during the benefit
year, I will have to repay the extra premium assistance
back to the IRS when I file my federal income taxes for the
benefit year.
I give my permission to Covered California to check
other agencies’ computer records to verify citizenship,
satisfactory immigration status, tax information, and other
information related only to eligibility to see if I and other
people on this application qualify for health insurance.
If someone on the application qualifies for Medi-Cal:
I know that if Medi-Cal pays for a medical expense, any
money I or anyone on this application gets from other
health insurance or legal settlements related to that
expense will go to Medi-Cal as payment for the expense
until the expense is paid in full.
For parents whose child or children qualify for Medi-Cal:
I know I will be asked to help the agency that collects
medical support from any parent on this application who
does not live with the child and does not send support
for the child. If I think that helping will harm me or my
children, I can tell
the Medi-Cal program
and I will not have
to help.
Your rights and responsibilities continued on next page
CCFRM604 (11/13) EN
Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). The call is free. You can call
Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.
Need help?
Step 3:
Please read and sign this application (continued)
Your rights and responsibilities
(continued)
Your right to appeal:
If I think Covered California or the Medi-Cal program has
made a mistake, I can appeal its decision. To appeal means
to tell someone at Covered California or the Medi-Cal
program that I think its decision is wrong and ask for a fair
review of the action.
I know that I can find out how to appeal by calling
1-800-300-1506 (TTY: 1-888-889-4500).
I know that I must file an appeal within 90 days of the
decision.
I know that I can represent myself or have someone
else represent me in my appeal, such as an authorized
representative, a friend, a relative, or a lawyer.
I know that if I need help, someone at Covered California,
the Medi-Cal program, or the county social services office
can explain my case to me.
Declaration and signature This is required.
Renewal of insurance
To make it easier to continue to get health insurance in future
years, I agree to allow Covered California to use computer
sources, such as the IRS, to check my income. If the sources show
I am still eligible, my insurance coverage can be renewed for
another 12 months and I won’t have to fill out a renewal form or
send other paperwork.
I understand that if I choose not to allow Covered California to
use computer sources, I must complete a renewal packet every
12 months in order to continue my health insurance.
I agree to allow Covered California or the Medi-Cal program to
check my information for:
5 years
4 years
3 years
2 years
1 year
OR
I do not want Covered California to check my tax returns at
renewal.
I declare under penalty of perjury that what I say below is true and correct.
I understood all questions on this application and gave true and correct answers as far as I know. Where I did not know the
answer myself, I made every reasonable attempt to confirm the answer with someone who did know.
I know that if I do not tell the truth on this application, there may be a civil or criminal penalty for perjury that may include up to
four years in jail. (See California Penal Code Section 126.)
I know that the information in this application will be used to decide if the people who are applying qualify for health insurance.
Covered California will keep the information private, as required by federal and California law.
I agree to notify Covered California by calling 1-800-300-1506 (TTY: 1-888-889-4500) or visiting CoveredCA.com if anything
changes on this application for any person applying for health insurance.
If I am selecting a health plan by filling out and submitting Attachment D, and if I am determined eligible by Covered California to
enroll in the plan I selected in Attachment D:
I understand that by signing here I am entering into a contract with the issuer of that plan.
I am at least 18 years of age or I am an emancipated minor, and I am mentally competent to sign a contract.
Signature of applicant or authorized representative Date
Step 3 continued on next page
17
CCFRM604 (11/13) EN
18
¿Preguntas?
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.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m.
O visite CoveredCA.com.
Step 3:
Please read and sign this application (continued)
Complete this section if you are a Covered California certified individual helping someone fill out this application.
I certify that as a Certified Enrollment Counselor, Certified Insurance Agent, or Certified Plan-Based Enroller, I helped
the applicant complete this application and that this service was free of charge. I also certify that I gave true and
correct answers to all questions on this application as far as I know. I explained to the applicant, in easy-to-understand
language, the risk to the applicant of providing inaccurate information, and the applicant understood the explanation.
Certified Enrollment Counselor
Name:
CEC number
Certified Enrollment Entity
Name:
CEE number
Certified Insurance Agent
Name:
License number
Certified Plan-Based Enroller Plan:___________________________________________________________
Name:
Certification number
Certied individual's signature
Date
The state will not compensate the Covered California Certified Enrollment Entity unless the Certified Enrollment Counselor fills out
this section completely and correctly when the application is submitted.
Step 4:
Mailing information and checklist
Mail your signed application to:
Covered California
P.O. Box 989725
West Sacramento, CA 95798-9725
Did you remember to:
Tell us about everyone in your family and household, even if they don’t
need insurance? See page 3 for the list of whom to include.
Ask your employer about any job-related insurance you may qualify for?
Sign this application on page 17? If you chose an authorized
representative, also sign page 15.
A few more questions (optional)
1. Would you like to be considered for all Medi-Cal programs?
Yes
No
There are other Medi-Cal programs for people 65 years old or older, people with a disability,
or people with special health care needs.
If you check yes, we will contact you to get information about your property and assets.
2. Have you had any recent changes in your life that made you want to apply for health insurance?
If yes, check all that apply.
Moved to California
No longer incarcerated
Gained citizenship or lawful presence
Newly eligible for premium assistance
Loss of health insurance
Applying for Medi-Cal
Gained dependent (by birth, marriage, or adoption)
American Indian or Alaska Native
Other
When did this life event occur?
(month / day / year) __________________________________________________
Step 4 continued on next page
CCFRM604 (11/13) EN
Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). The call is free. You can call
Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.
Need help?
Step 4:
Mailing information and checklist (continued)
How did you hear about Covered California?
Check all that apply.
Outreach and education program
TV ad
Radio ad
Online ad
Email
Magazine or newspaper ad
Mailer
Internet search
News program or story
Social media (e.g., Facebook, Twitter, etc.)
Mobile app
Community organization or event
Billboard
Sign in retail store
Friend or family
Brochure
Certified Insurance Agent
Certified Enrollment Counselor
Employer
Church
CoveredCA.com website
Pharmacy
Provider or hospital
Government office
Word of mouth
Other _____________________________________________
Need more information about other programs?
Beginning January 1, 2014, would you and your household like to share the information you
just provided in a referral to your local Health and Human Services Agency for other programs?
Families that include immigrants can apply. You can apply for your child even if you aren’t eligible
for coverage. Applying for your eligible child won’t affect your immigration status or chances of
becoming a permanent resident or citizen.
To apply for nutrition or cash assistance before January 1, 2014, visit benefitscal.org. Or to apply
in person, call 1-877-847-3663 for a list of places near where you live or work.
For benefits after January 1, 2014, check which programs you want a referral for:
CalFresh A program that helps people pay for food. Benefits are renewed monthly on a debit
card that can be used to buy most foods at many markets and stores. It is also known as the
Supplemental Nutrition Assistance Program (SNAP). Visit www.calfresh.ca.gov for more information.
CalWORKs A program that gives cash assistance and support services to low-income families
with children to help pay for housing, food, and other necessary expenses.
You may also find more information about these programs online:
Access for Infants and Mothers (AIM)
A program that helps pregnant women get health care
aim.ca.gov
Child Health and Disability Prevention (CHDP)
A preventive program that delivers periodic health
assessments and services to low-income children
www.dhcs.ca.gov/services/chdp
Early and Periodic Screening, Diagnosis, and
Treatment (EPSDT)
A Medi-Cal program for children and young adults under
the age of 21
–
it allows for regular checkups to identify
health care needs, followed by diagnosis and treatment
when necessary
www.dhcs.ca.gov/services/Pages/EPSDT.aspx
Family Planning, Access, Care, Treatment
(Family PACT)
A program that provides no-cost family planning
services to low-income men and women,
including teens
familypact.org
In-Home Supportive Services Program (IHSS)
A program that will help pay for services provided
to you so that you can remain safely in your own home
www.cdss.ca.gov/agedblinddisabled/pg1296.htm
Women, Infants, and Children (WIC)
A nutrition program
for pregnant women, new mothers,
and children under the age of 5
www.wicworks.ca.gov
19
CCFRM604 (11/13) EN
20
¿Preguntas?
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.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m.
O visite CoveredCA.com.

Attachment A:
For American Indians or Alaska Natives
Complete this if you or a family member is American Indian or Alaska Native.
American Indians and Alaska Natives can get services from the Indian Health Services, tribal health programs, or urban
Indian health programs. Federally recognized American Indians and Alaska Natives also may not have to pay out-of-
pocket costs (such as copayments) and may get special enrollment periods. Be sure to complete this form and send it
in with your application and your proof of American Indian or Alaska Native heritage. You may send a document from a
federally recognized Indian tribe that shows you are a member of the tribe or affiliated with the tribe. Documents may
include a tribal enrollment card or certificate of degree of Indian blood (CDIB) from the Bureau of Indian Affairs. If you
think you qualify for Medi-Cal, you do not have to send proof. See Attachment F to see if you can qualify for Medi-Cal.
If you need to tell us about more than four people who are American Indians or Alaska Natives, make a copy of this page,
and be sure to send it with your application.
Person 1:
First name Middle name Last name Suffix (examples: Sr., Jr., III, IV)
Is this person a member of a federally recognized American Indian or Alaska Native tribe?
Yes
No
If yes, write the name of the tribe: _______________________________________________________________________________ and the state of the tribe: __________________________________________________
Has this person ever gotten a service from the Indian Health Service, a tribal health program, or an 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, a tribal health program, or an urban Indian health
program or through a referral from one of these programs?
Yes
No
Does this person get income from any of the sources below?
Yes If yes, fill in the amount and frequency below.
No If no, continue the application.

Payments to the tribe that come from natural resources, usage rights, leases, or royalties
Amount $ _________________________________
Weekly
Every two weeks
Monthly
Other _______________________________________________________

Payments from leases or royalties for the use of Indian trust land for natural resources, farming, ranching, or shing
Amount $ _________________________________
Weekly
Every two weeks
Monthly
Other _______________________________________________________

Money from selling things that have cultural value
Amount $ _________________________________
Weekly
Every two weeks
Monthly
Other _______________________________________________________
Person 2:
First name Middle name Last name Suffix (examples: Sr., Jr., III, IV)
Is this person a member of a federally recognized American Indian or Alaska Native tribe?
Yes
No
If yes, write the name of the tribe: _______________________________________________________________________________ and the state of the tribe: __________________________________________________
Has this person ever gotten a service from the Indian Health Service, a tribal health program, or an 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, a tribal health program, or an urban Indian health
program or through a referral from one of these programs?
Yes
No
Does this person get income from any of the sources below?
Yes If yes, fill in the amount and frequency below.
No If no, continue the application.

Payments to the tribe that come from natural resources, usage rights, leases, or royalties
Amount $ _________________________________
Weekly
Every two weeks
Monthly
Other _______________________________________________________

Payments from leases or royalties for the use of Indian trust land for natural resources, farming, ranching, or shing
Amount $ _________________________________
Weekly
Every two weeks
Monthly
Other _______________________________________________________

Money from selling things that have cultural value
Amount $ _________________________________
Weekly
Every two weeks
Monthly
Other _______________________________________________________
CCFRM604 (11/13) EN
Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). The call is free. You can call
Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.
Need help?
Attachment A:
For American Indians or Alaska Natives (continued)
Person 3:
First name Middle name Last name Suffix (examples: Sr., Jr., III, IV)
Is this person a member of a federally recognized American Indian or Alaska Native tribe?
Yes
No
If yes, write the name of the tribe: _______________________________________________________________________________ and the state of the tribe: __________________________________________________
Has this person ever gotten a service from the Indian Health Service, a tribal health program, or an 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, a tribal health program, or an urban Indian health
program or through a referral from one of these programs?
Yes
No
Does this person get income from any of the sources below?
Yes If yes, fill in the amount and frequency below.
No If no, continue the application.

Payments to the tribe that come from natural resources, usage rights, leases, or royalties
Amount $ _________________________________
Weekly
Every two weeks
Monthly
Other _______________________________________________________

Payments from leases or royalties for the use of Indian trust land for natural resources, farming, ranching, or shing
Amount $ _________________________________
Weekly
Every two weeks
Monthly
Other _______________________________________________________

Money from selling things that have cultural value
Amount $ _________________________________
Weekly
Every two weeks
Monthly
Other _______________________________________________________
Person 4:
First name Middle name Last name Suffix (examples: Sr., Jr., III, IV)
Is this person a member of a federally recognized American Indian or Alaska Native tribe?
Yes
No
If yes, write the name of the tribe: _______________________________________________________________________________ and the state of the tribe: __________________________________________________
Has this person ever gotten a service from the Indian Health Service, a tribal health program, or an 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, a tribal health program, or an urban Indian health
program or through a referral from one of these programs?
Yes
No
Does this person get income from any of the sources below?
Yes If yes, fill in the amount and frequency below.
No If no, continue the application.

Payments to the tribe that come from natural resources, usage rights, leases, or royalties
Amount $ _________________________________
Weekly
Every two weeks
Monthly
Other _______________________________________________________

Payments from leases or royalties for the use of Indian trust land for natural resources, farming, ranching, or shing
Amount $ _________________________________
Weekly
Every two weeks
Monthly
Other _______________________________________________________

Money from selling things that have cultural value
Amount $ _________________________________
Weekly
Every two weeks
Monthly
Other _______________________________________________________
21
CCFRM604 (11/13) EN
22
¿Preguntas?
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.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m.
O visite CoveredCA.com.

Attachment B:
Tell us about your family’s health insurance
If you need to tell us about more than four people who have other health insurance,
make a copy of this page, and be sure to send it with your application.
Tell us about the health insurance you have now
Answer these questions for everyone who needs help paying for health insurance.
We need to know if anyone applying for health insurance has coverage now. You do not have to tell us about coverage
that is not considered minimum essential coverage. Examples of the types of plans you don't have to tell us about are:
Indian Health Service, tribal health program, urban Indian health program, flex savings plans, health savings accounts,
or insurance available in another country.
We do need to know if anyone has any of the following health insurances now: COBRA, employer-sponsored insurance,
Peace Corps, retiree health plan, TRICARE/CHAMPUS, veterans health program, or other health insurance. Does anyone
have any of these insurances?
Yes If yes, fill in this page. If you need more space, attach another sheet of paper.
No If no, go to page 23.
Note: If you have private health insurance you bought on your own, check the box for “Other health insurance” under
“What type?” in the table below.
Name First, middle, last, suffix (for example, Jr., Sr., III, IV) What type? (choose one)
Person 1:
_______________________________________________________________________________
COBRA
Veteran's health program
Has this person been offered affordable full-coverage health
Employer-sponsored insurance
Retiree health plan
insurance for January 2014?
Yes
No
Peace Corps
Other health insurance
TRICARE/CHAMPUS
Person 2: _______________________________________________________________________________
COBRA
Veteran's health program
Has this person been offered affordable full-coverage health
Employer-sponsored insurance
Retiree health plan
insurance for January 2014?
Yes
No
Peace Corps
Other health insurance
TRICARE/CHAMPUS
Person 3: _______________________________________________________________________________
COBRA
Veteran's health program
Has this person been offered affordable full-coverage health
Employer-sponsored insurance
Retiree health plan
insurance for January 2014?
Yes
No
Peace Corps
Other health insurance
TRICARE/CHAMPUS
Person 4: _______________________________________________________________________________
COBRA
Veteran's health program
Has this person been offered affordable full-coverage health
Employer-sponsored insurance
Retiree health plan
insurance for January 2014?
Yes
No
Peace Corps
Other health insurance
TRICARE/CHAMPUS
Attachment B continued on next page
CCFRM604 (11/13) EN
Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). The call is free. You can call
Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.
Need help?
__________________________________
Attachment B:
Tell us about your family's health insurance (cont'd)
Employer health insurance Answer these questions for everyone who needs help paying for health insurance.

We need to know about any health insurance you could get through someone’s job. You can use Attachment C,
Employer Insurance Form, on page 24 to help you complete this section. Answer these questions or use
Attachment C only if someone in the household qualifies for health insurance from someone’s job.
Is anyone on this application offered health insurance by an employer?
This could be someone else’s job, such as a parent's or a spouse's. It could also include COBRA, TRICARE, federal or state employer,
private employer, or Peace Corps plans. You may have additional health insurance that you do not have to report to us. The following
are examples of additional coverage (not considered minimum essential coverage) you do not have to tell us about: flex savings plans,
health savings accounts, disability insurance, or insurance available in another country.
Yes If yes, answer these questions. If you need more space, attach another sheet of paper.
No If no, go back to the application to continue.
Name
First, middle, last, suffix
(for example, Jr., Sr., III, IV)
Employer name (optional) This person:
How much does
this person
pay in monthly
premiums?
Does this health
plan meet
the minimum
value standard*?
Person 1:
Is enrolled now
Plans to enroll
Start date
____________________________
Is not enrolled
$
Yes
No
I don't know
Person 2:
Is enrolled now
Plans to enroll
Start date
____________________________
Is not enrolled
$
Yes
No
I don't know
Person 3:
Is enrolled now
Plans to enroll
Start date
____________________________
Is not enrolled
$
Yes
No
I don't know
Person 4:
Is enrolled now
Plans to enroll
Start date
____________________________
Is not enrolled
$
Yes
No
I don't know
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.)
How much will the employee have to pay in
premiums for that plan?
$ _______________________
How often? ______________________________________
Weekly
Every 2 weeks
Quarterly
Monthly
Twice a month
Yearly
Date of change
*Minimum value standard means that a plan pays at least 60% of the total cost of plan
benefits provided to the employee. (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)
23
CCFRM604 (11/13) EN
24
¿Preguntas?
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.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m.
O visite CoveredCA.com.
Attachment C:
Employer Insurance Form
TM
This form is only necessary for those who qualify for health insurance through a job.
It is not necessary for some health insurance programs offered through Covered California,
including Medi-Cal. If you are not sure whether or not to use this form, call Covered California to ask:
1-800-300-1506 (TTY: 1-888-889-4500). If you think you qualify for Medi-Cal, you do not need to fill out
this form. To see if you qualify for Medi-Cal or premium assistance, see Attachment F on page 28.
If more than one job offers health coverage, use a separate form for each employer.

Employee information You need to fill out this section.

Fill in your name and Social Security number (SSN) (optional). Then make a copy of this page or take the application to your
employer. Ask your employer to fill in the rest of the page. If you copy the page, be sure to send it with your application.
Employee: First name Middle name Last name Suffix
Social Security number (SSN) (optional)
___
–
__
–
____

Employer information Ask your employer for this information.

Note for employer: To complete the Covered California application, we need to know about health
insurance that your employee or their dependents might be able to get from you. Please complete the
information below, even if your company does not offer health insurance.
Employer name:
Employer Identication Number (EIN)
__
–
_______
Employer address Employer phone number
City State
ZIP code
Whom can we contact about employee health coverage at this job?
Phone number Email address
We do not offer health insurance.
This employee does not qualify for coverage under our plan.
The employee qualifies for coverage under our plan beginning on ____________________________________________ (start date).
What’s the name of the lowest-cost, self-only health plan this employee could
enroll in at this job? Consider only those plans that meet the minimum value
standard* set by the Federal Patient Protection and Affordable Care Act of 2010.
If you’re not sure, ask your health insurance issuer.
Name:
__________________________________________________________________________________________________________
No plans meet the minimum value standard.*
What change will you make for the new plan year (if known)?
We won’t offer health coverage.
We 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.)
How much would the employee have to pay in
premiums for the lowest cost?
$________________
How often? _____________________________________
Weekly
Every 2 weeks
Quarterly
Monthly
Twice a month
Yearly
Other _______________________________________
How much will the employee have to pay in
premiums for that plan?
$ ______________________
How often? _____________________________________
Weekly
Every 2 weeks
Quarterly
Monthly
Twice a month
Yearly
Date of change _________________________________
*Minimum value standard means that a plan pays at least 60% of the total cost of plan benefits provided to the employee. (Section 36B(c)(2)(C)(ii) of the
Internal Revenue Code of 1986)
CCFRM604 (11/13) EN
Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). The call is free. You can call
Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.
Need help?

Attachment D:
Choose your pediatric dental plan and
your health insurance plan
If you need to tell us about more than four people who would like to choose a pediatric dental
plan or health insurance plan, make a copy of this page and the next page, and be sure to send
them with your application.
If you think you qualify for premium assistance, write the name or metal tier of the pediatric dental plans or
health insurance plans you want below. To learn more about private plans provided by Covered California,
visit CoveredCA.com or call 1-800-300-1506 (TTY: 1-888-889-4500).
If you think you qualify for Medi-Cal, write the name of the health insurance plan you want below.
To learn more about available Medi-Cal plans in your county, or to change your plan once you are enrolled,
call Health Care Options at 1-800-430-4263 (TTY: 1-800-430-7077), or visit healthcareoptions.dhcs.ca.gov.
To see if you qualify for Medi-Cal or premium assistance, look at Attachment F.

Choose your Covered California pediatric dental plan for children 18 or younger only
Name
First, middle, last, suffix (for example, Jr., Sr., III, IV)
Pediatric dental plan name
Coverage
level Plan type
Child 1:
High
Low
DEPO
DPPO
DHMO
Child 2:
High
Low
DEPO
DPPO
DHMO
Child 3:
High
Low
DEPO
DPPO
DHMO
Child 4:
High
Low
DEPO
DPPO
DHMO
DEPO–Dental Exclusive Provider Organization; DHMO–Dental Health Maintenance Organization; DPPO–Dental Preferred Provider Organization

Choose your health insurance plan
Medi-Cal and Covered California plans Covered California plans only
Name First, middle, last, suffix
(for example, Jr., Sr., III, IV)
Health plan name
Metal tier
Metal
number Plan type
Person 1:
Platinum
Gold
Silver
Bronze
Minimum coverage plan
EPO
HSA
HMO
PPO
Person 2:
Platinum
Gold
Silver
Bronze
Minimum coverage plan
EPO
HSA
HMO
PPO
Person 3:
Platinum
Gold
Silver
Bronze
Minimum coverage plan
EPO
HSA
HMO
PPO
Person 4:
Platinum
Gold
Silver
Bronze
Minimum coverage plan
EPO
HSA
HMO
PPO
EPO–Exclusive Provider Organization; HMO–Health Maintenance Organization; HSA–Health Savings Account (this plan type allows members to open and
contribute to a Health Savings Account); PPO–Preferred Provider Organization
To complete plan selection, all individuals age 18 or older who are selecting a health insurance plan
must agree to and sign the arbitration agreement on the next page.
Attachment D continued on next page
25
CCFRM604 (11/13) EN
26
¿Preguntas?
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.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m.
O visite CoveredCA.com.
Attachment D:
Choose your Covered California plans (continued)
Agreement for Binding Arbitration
For each person who selects a Covered California plan:
I understand that every participating health plan has its own rules for resolving disputes or claims,
including, but not limited to, any claim asserted by me, my enrolled dependents, heirs, or authorized
representatives against a health plan, any contracted health care providers, administrators, or other
associated parties, about the membership in the health plan, the coverage for, or the delivery of, services or
items, medical or hospital malpractice (a claim that medical services were unnecessary or unauthorized or
were improperly, negligently, or incompetently rendered), or premises liability.
I understand that, if I select a health plan that requires binding arbitration to resolve disputes, I accept, and
agree to, the use of binding arbitration to resolve disputes or claims (except for Small Claims Court cases
and claims that cannot be subject to binding arbitration under governing law) and give up my right to a jury
trial and cannot have the dispute decided in court, except as applicable law provides for judicial review of
arbitration proceedings. I understand that the full arbitration provision for each participating health plan,
if they have one, is in the health plan’s coverage document, which is available online at CoveredCA.com for
my review, or, I can call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500) for more information.
For each person who selects a Kaiser Medi-Cal health plan:
Notice of binding arbitration: I have read the plan description. I understand that Kaiser requires the use
of binding neutral arbitration to resolve certain disputes. This includes disputes about whether the right
medical treatment was provided (called medical malpractice) and other disputes relating to benefits or the
delivery of services, including whether any medical services provided were unnecessary or unauthorized,
or were improperly, negligently, or incompetently rendered. If I pick Kaiser as my Medi-Cal health plan, I
give up my constitutional right to a jury or court trial for those certain disputes. I also agree to use binding
neutral arbitration to resolve those certain disputes. I do not give up my right to a state hearing of any issue,
which is subject to the state hearing process.
Signatures of enrollees for all plans
Signature of Person 1, or responsible party, or authorized representative for Person 1, if at least 18 years old
Date
Signature of Person 2, or responsible party, or authorized representative for Person 2, if at least 18 years old
Date
Signature of Person 3, or responsible party, or authorized representative for Person 3, if at least 18 years old
Date
Signature of Person 4, or responsible party, or authorized representative for Person 4, if at least 18 years old
Date
CCFRM604 (11/13) EN
Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). The call is free. You can call
Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.
Need help?
Attachment E:
Step 2 references
Use these lists to answer the questions in Step 2.
Immigration status Self-employment
Use this list for "Applying for health insurance"
Use this list for "Are you self-employed?"
If you have one of these immigration statuses, you may
You can subtract these items from your gross income to
qualify for health insurance:
find your net self-employment income. See “Instructions for
Lawful Permanent Resident (LPR, or Greencard holder)
Lawful Temporary Resident (LTR)
Asylee
Refugee
Cuban/Haitian entrant
Paroled into the U.S.
Conditional entrant granted before 1980
Battered spouse, child, or parent
Victim of trafficking and his or her spouse, child,
sibling, or parent
Individual with non-immigrant status (includes worker
visas, student visas, and citizens of Micronesia, the
Marshall Islands, and Palau)
Temporary Protected Status (TPS) or applicant for
Temporary Protected Status (TPS)
Deferred Enforced Departure (DED)
Deferred action status Note: If you are an individual with
deferred action status under the Department of Homeland
Security's deferred action for childhood arrivals in process
(DACA), you are not considered to be lawfully present.
Granted withholding of deportation or withholding
of removal, under the immigration laws or under the
Convention against Torture (CAT)
Applicant for withholding of deportation or withholding
of removal, under the immigration laws or under the
Convention against Torture (CAT)
Applicant for special immigrant juvenile status
Applicant for adjustment to LPR status, with approved
visa petition
Applicant for asylum
Registry applicants with Employment Authorization
Document (EAD)
Order of supervision (with EAD)
Applicant for cancellation of removal or suspension of
deportation (with EAD)
If your immigration status is not listed above, you may
still qualify for health insurance and should still apply.
Schedule C” at irs.gov for more information.
Car and truck expenses (workday travel, not commuting)
Depreciation
Employee wages and fringe benefits
Property, liability, or business interruption insurance
Interest (for example, mortgage interest paid to banks)
Legal and professional services
Rent or lease of business property and utilities
Commissions, taxes, licenses, and fees
Advertising
Contract labor
Repairs and maintenance
Certain business travel and meals
Examples of other income
Use this list for "Do you have other income?"
Unemployment benefits
Social Security benefits
Retirement or pension income
Rent or royalty income
Alimony received
Investment income
Capital gains
Farming or fishing income
Canceled debts
Court awards
Jury duty pay
Miscellaneous
Deductions
Use this list for "Do you have deductions?"
Certain self-employment expenses
Student loan interest deduction
Tuition and fees
Educator expenses
IRA contribution
Moving expenses
Penalty on early withdrawal of savings
Health savings account deduction
Alimony paid
Domestic production activities deduction
Certain business expenses of reservists, performing
artists, and fee-basis government officials
27
CCFRM604 (11/13) EN
28
¿Preguntas?
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.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m.
O visite CoveredCA.com.
Attachment F:
Federal Poverty Guidelines

Estimate what type of health insurance you may be eligible for in 2014.
Number of
people in your
household
If your annual household
income is less than:
If your annual household
income is between:
1 $15,860* $15,860 – $45,960
2 $21,400 $21,400 – $62,040
3 $26,950 $26,950 – $78,120
4 $32,500 $32,500 – $94,200
5 $38,050 $38,050 – $110,280
È È
You may be eligilble You may be eligible
for Medi-Cal. for insurance with financial
help through Covered
California.
*These annual household income amounts are approximate only and based on 2013 income data.
If you already have affordable insurance from your employer or a government program like
Medicare or Medicaid, you will not be eligible for Covered California health insurance plans.
If you have children or are pregnant, you can have higher income and still qualify for free
or low-cost insurance through Medi-Cal or AIM. If you are pregnant, you and your expected
baby (or babies) are counted as separate persons to qualify for Medi-Cal and as one person
for financial help through Covered California.
CCFRM604 (11/13) EN
Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). The call is free. You can call
Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.
Need help?
Frequently Asked Questions (FAQ)
Getting help through Covered
California
1. What is Covered California?
Covered California is the new marketplace that makes it
possible for individuals and families to get free or low-
cost health insurance through Medi-Cal, or to get help
paying for private health insurance available through
Covered California.
Our goal is to make it simple and affordable for
Californians to get health insurance. Covered California
is a partnership of the California Health Benefit Exchange
and the California Department of Health Care Services.
2. What is Medi-Cal?
Medi-Cal is California’s version of the federal Medicaid
program. It is free or low-cost health insurance for
California residents who qualify.
3. What is Access for Infants and Mothers
(AIM)?
AIM is a low-cost health insurance program for pregnant
women who don’t have health insurance and whose
income is too high for no-cost Medi-Cal. AIM is also
available to women who have private health insurance
plans with a maternity-only deductible or copayment
greater than $500.
4. How can Covered California help me?
Covered California can help you choose a private
insurance plan that meets your health needs and
budget. We offer some of the state’s best-known health
plans, and some regional or local plans too.
We can explain the costs and benefits of health
insurance plans clearly, so you can compare the
different choices available to you. You will know exactly
what you’re getting and how much you have to pay
before you choose your plan.
5. Can I get health insurance even if my
income is too high?
Yes. Any Californian who qualifies can purchase private
health insurance through Covered California regardless
of income. We use your income to help us find the
health insurance that is most affordable for your family.
6. What health insurance is offered through
Covered California?
You will have a wide variety of health plans to choose
from. Health insurance companies cannot refuse to
cover you because you have been sick before or could
not get coverage.
Covered California offers four groups of private health
insurance plans: platinum, gold, silver, and bronze, plus
a minimum-coverage plan.
Each group offers a different level of coverage, from high
to low. Health insurance plans that cover more of your
medical expenses will usually have a higher premium
but allow you to pay less when you receive medical care.
Platinum plans have the highest premium, but they
pay roughly 90% of your health care expenses. Gold
plans pay roughly 80%, and silver plans pay roughly
70% of your health care expenses. Bronze plans have
the lowest premium but pay roughly 60% of covered
health expenses. To learn more about the full benefit
packages available, please visit CoveredCA.com and
review the plan documents, such as the plan’s Evidence
of Coverage, or the plan’s insurance policy. Or call us at
1-800-300-1506 (TTY: 1-888-889-4500).
If you qualify for Medi-Cal, the coverage and costs are
different and may be free for you.
7. Can I get health insurance through
Covered California?
Any Californian can get health insurance through
Covered California if he or she is a state resident and
meets other requirements.
Applicants may qualify for a free or low-cost health plan,
or for financial help that can lower the cost of premiums
and copayments. The amount of financial help is based
on household size and family income. Applicants qualify
if their income meets the income limits.
8. How much does it cost?
The cost depends on what health insurance programs
and financial assistance you qualify for, as well as which
plan you choose. You can use the cost calculator at
CoveredCA.com to find the cost and see if you qualify
for help paying insurance.
Frequently Asked Questions continued on next page
29
CCFRM604 (11/13) EN
30
¿Preguntas?
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.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m.
O visite CoveredCA.com.
Frequently Asked Questions (continued)
Getting help through Covered
California
(continued)
9. Should I include my first premium payment
with this application?
No, do not send your first payment with this application.
Your plan will send you an invoice for the amount you owe.
10. How do I apply?
You can apply for health insurance through Covered
California in the following ways:
Online:
Visit CoveredCA.com. We provide information
about each health insurance plan, explained in clear
and simple terms.
By phone:
Call Covered California at 1-800-300-1506
(TTY: 1-888-889-4500). You can call Monday through
Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m.
The call is free!
By fax:
Fax your application to 1-888-329-3700.
By mail:
Mail the Covered California application to:
Covered California
P.O. Box 989725
West Sacramento, CA 95798-9725
In person:
We have trained Certified Enrollment
Counselors or Certified Insurance Agents who can
help you. Or you can visit your county social services
office. This help is free! For a list of places near
where you live or work, visit CoveredCA.com or call
1-800-300-1506 (TTY: 1-888-889-4500).
11. I am currently enrolled in Medi-Cal.
Can I get health insurance through
Covered California?
If your income changes during the year or at your annual
renewal, you may qualify for other health insurance and
premium assistance through Covered California.
12. What if I already have health insurance?
If you already have affordable health insurance from
your employer, you do not need to do anything.
But you can still apply anyway to find out if you or your
family members qualify for free or low-cost health
insurance.
If you apply, be sure to complete Attachment B and
send it in with your application.
13. Do I need health insurance now that health
reform has started?
Starting in January 2014, most people, including
children, will be required to have health insurance or
pay a tax penalty. Coverage may include insurance
through your job, coverage you buy on your own,
Medicare, or Medi-Cal.
But some people are exempt from having health
insurance. Those people include, but are not limited
to, members of federally recognized religious sects
or divisions whose religious beliefs are opposed to
accepting benefits from a health insurance plan, people
who are incarcerated, people who are members of a
federally recognized American Indian or Alaska Native
tribe, and those people who have to pay more than
8% of their income for health insurance, after taking
into account any employer contributions or premium
assistance.
In 2014, the penalty will be 1% of your yearly income
or $95, whichever is higher. The penalty will go up each
year. By 2016, the penalty will be 2.5% of your yearly
income or $695, whichever is higher. After 2016, the tax
penalty will increase each year based on a cost-of-living
adjustment.
For more information about penalties, visit
CoveredCA.com or call your local county social services
office or Covered California
.
14. I don’t have all the information I need to
answer the questions on the application.
What should I do?
If you don’t have all the information, sign and submit
your application anyway. We will call you to tell you
what to do within 10 to 15 calendar days after we get
your application. If you don't hear from us, please call
us at
1-800-300-1506 (TTY: 1-888-889-4500)
.
15. What will happen after I apply?
We will send you a letter within 45 days to tell you which
program you and your family members qualify for. If
you don't hear from us, please call us at 1-800-300-1506
(TTY: 1-888-889-4500).
Frequently Asked Questions continued on next page
CCFRM604 (11/13) EN
Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). The call is free. You can call
Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.
Need help?
Frequently Asked Questions (continued)
Getting help through Covered
California
(continued)
16. Can I get help with my application or with
choosing a plan?
Yes! Help is free. Certified Enrollment Counselors and
Certified Insurance Agents are available in communities
across the state to give you information about new
health insurance choices and help you apply. You can
also get help by visiting your county social services
office. You can get help in many different languages.
Get help with your application or with choosing a plan:
Online:
Visit CoveredCA.com. We provide information
about each health insurance plan, explained in clear
and simple terms.
By phone:
Call Covered California at 1-800-300-1506
(TTY: 1-888-889-4500). You can call Monday through
Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m.
The call is free!
In person:
We have trained Certified Enrollment
Counselors and Certified Insurance Agents who can
help you. Or you can visit your county social services
office. This help is free! For a list of places near
where you live or work, visit CoveredCA.com or call
1-800-300-1506 (TTY: 1-888-889-4500)
.
17. How can I choose a health insurance plan?
If you qualify for private health insurance plans through
Covered California, you can visit CoveredCA.com to easily
shop and compare health insurance plans. Covered
California health plan brochures are also available for you.
Covered California will offer choices of private health
insurance plans and Medi-Cal plans. You can choose the
level of coverage that best meets your health needs and
budget.
You can choose to pay a higher monthly cost (called a
premium) so that you pay less out of pocket when you
need medical care.
Or, you can choose to pay a lower monthly cost but
pay more out of pocket when you need care.
If you qualify for Medi-Cal, the coverage and costs are
different, and they may even be free. To learn more
about available Medi-Cal plans in your county, call Health
Care Options at 1-800-430-4263 (TTY: 1-800-430-7077).
Or, visit www.healthcareoptions.dhcs.ca.gov.
Financial assistance
18. I don't make a lot of money. What
programs are available to help me get
health insurance?
Starting on January 1, 2014, people who need health
insurance may be able to get help in one of these ways:
A. Assistance with monthly premiums. Premium
assistance is available to help make health insurance
affordable. People who qualify for premium
assistance can get the assistance in advance (before
they file taxes) to make their monthly premiums
lower. Or they can get the assistance at the end of
the year and pay less in taxes.
The amount of assistance for monthly premiums
depends upon your household size and family income.
B. Medi-Cal: Medi-Cal is California’s Medicaid program,
paid for with federal and state taxes. It’s health
insurance for low-income California residents who
meet certain requirements.
If your income is within the Medi-Cal limits for your
family size, you will receive Medi-Cal coverage at no
cost to you.
19. If my income changes, will my premium
assistance change immediately?
No, your premium assistance will not change
immediately. We will process any new information
we have. And, we will tell you if the amount of your
premium assistance changes.
20. If my income changes, how will the change
affect me when I file my taxes?
It is important to report income changes to Covered
California that affect the amount of premium
assistance (or tax credits) that you receive. If your
income decreases, you may qualify to receive a higher
amount of premium assistance and reduce your
out-of-pocket expenses even more. However, if your
income increases, you may receive too much premium
assistance and may be required to repay some of it back
when you file your taxes for the benefit year.
Frequently Asked Questions continued on next page
31
CCFRM604 (11/13) EN
32
¿Preguntas?
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.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m.
O visite CoveredCA.com.
Frequently Asked Questions (continued)
Financial assistance (continued)
21. What if I didn’t file taxes last year?
If you didn't file taxes last year, you can still apply for
health insurance and get premium assistance. We will
use your income to help us find the health insurance
that is most affordable for you and your family.
If you qualify for premium assistance, you must file
taxes for the benefit year.
22. What if my income changes after I apply?
If your income changes, it may change what kind of
health insurance you qualify for.
If you have private health insurance through Covered
California, call to report any change in your income that
may affect your eligibility within 30 days.
If you have Medi-Cal and your income changes, contact
your county social services office within 10 days.
Other questions
23. Does everyone on the application have
to be a U.S. citizen or U.S. national?
No. You may qualify for health insurance through
Medi-Cal even if you are not a U.S. citizen or a U.S.
national.
24. Will my family and I qualify for the same
program?
Depending on your household size or family income,
you or your family may qualify for different programs.
For example, you may qualify for affordable private
health insurance available through Covered California.
However, your child may qualify for free Medi-Cal.
We will tell you which health insurance you and other
members qualify for.
25. This application asks for a lot of personal
information. Will Covered California share
my personal and financial information?
No. The information you provide is private and
secure, as required by federal and state law. We use
your information only to see if you qualify for health
insurance.
26. Will I be able to use my new Covered
California health insurance plan right
away?
If you are applying between October and December,
2013, health plans start providing services as early as
January 1, 2014. If you are applying after January 1,
2014, your health plan may be able to start providing
services as soon as the month after you apply.
27. What do you mean by “disability”?
You may have a disability and qualify for Medi-Cal if:
You are deaf or have a serious hearing loss.
You are blind or have a serious vision loss, even when
wearing glasses.
You have an intellectual or cognitive disability and
have difficulty remembering, concentrating, or making
decisions.
You have an ambulatory condition and have difficulty
walking or climbing the stairs.
You have difficulty bathing or dressing or doing similar
daily activities.
You have a physical, mental, or emotional condition
and have difficulty doing errands (such as shopping or
visiting a doctor’s office) without help.
You do not have to be receiving special assistance
services in your home or living in any kind of nursing
facility or assisted living facility.
28. I have a pre-existing condition or disability.
Can I get health insurance through
Covered California?
Yes, you can get health insurance regardless of any
current or past health conditions or disability.
Starting in 2014, most health insurance plans can’t
refuse to cover you or charge you more just because
you have a pre-existing health condition or disability.
29. I just found out I am pregnant.
Can I apply for health insurance that will
cover me during my pregnancy?
Yes. Make sure to answer yes to the application
question “Are you pregnant?” or tell the person helping
you to fill out your application. You can apply for health
insurance that can cover prenatal care, labor and
delivery, and postpartum care. Health insurance plans
can no longer deny you health insurance if you are
pregnant.
Frequently Asked Questions continued on next page
CCFRM604 (11/13) EN
Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). The call is free. You can call
Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.
Need help?
Frequently Asked Questions (continued)
Other questions (continued)
30. I just had a new baby. What should I do
about health insurance?
If you did not have Medi-Cal or Access for Infants
and Mothers (AIM) at the time of delivery, fill out this
application for your newborn.
If you did have Medi-Cal or AIM during your pregnancy,
you do not need to fill out this application.
Include the mother’s information on page 2 of this
application.
If you had Medi-Cal, call your county social services
office to make sure your baby is covered from birth,
or fill out a newborn referral form. Print the form
at www.dhcs.ca.gov/formsandpubs/forms/Forms/
mc330.pdf.
If you had AIM, call 1-800-433-2611, or go to
aim.ca.gov to register your baby.
31. Will I qualify for health insurance if I am
not a citizen or do not have satisfactory
immigration status?
Anyone who lives in California can apply for health
insurance using this application. Only people who
are applying must provide Social Security numbers or
information about immigration status.
But you may qualify for certain health insurance
programs regardless of your immigration status and
even if you do not have a Social Security number.
We keep your information private and only share
information with other government agencies to see
which programs you qualify for.
32. Were you in foster care on your 18th
birthday?
If you were in foster care and getting Medicaid in any
state when you turned 18, and you are now between
the ages of 18 and 26, you may qualify for Medi-Cal.
After we verify that you are a California resident, we will
enroll you in Medi-Cal for free. Then we will verify that
you were in foster care and Medicaid before.
33. What constitutes a one-time payment?
One-time payments are only allowed for gambling
winnings, prizes, cancellation of debt, salary or wages
from decedents’ employer received by a surviving
spouse, retroactive social security and railroad
retirement benefits, lottery winnings, gifts, and
retroactive unemployment insurance benefits.
34. What does “self-employed” mean?
People who are self-employed earn a living directly from
their own business or services. They do not earn money
from a company that pays them.
35. Where can I get information about
becoming registered to vote?
If you are not registered to vote where you live now and
would like to apply to register to vote today, please visit
registertovote.ca.gov. Or, call 1-800-345-VOTE (8683).
36. I am an American Indian or an
Alaska Native. How can Covered
California help me?
If you are a federally recognized American Indian or
Alaska Native, or if you qualify in another way for
services from the Indian Health Services, tribal health
programs, or urban Indian health programs, you
may qualify for free or low cost Medi-Cal. Or you may
qualify for other cost savings, such as assistance paying
premiums or no copayments. You may also have special
monthly enrollment times.
Complete Attachment A and send it with proof that
you are an American Indian or
Alaska Native
. You can
use a tribal enrollment card or Certificate of Degree of
Indian Blood (CDIB) from the Bureau of Indian Affairs.
If you qualify for Medi-Cal, you do not need to send
proof of your American Indian or
Alaska Native
heritage. To see if you qualify for Medi-Cal, see
Attachment F.
37. What if I don’t agree with the decision
Covered California makes?
You can file an appeal. To appeal a decision you don’t
agree with, contact Covered California in one of these
ways:
Online: Visit CoveredCA.com.
By phone: Call Covered California at 1-800-300-1506
(TTY: 1-888-889-4500). You can call Monday through
Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m.
The call is free!
By fax: Fax the appeal to 1-888-329-3700.
By mail: Mail the appeal to:
Covered California – Appeals
P.O. box 989725
West Sacramento, CA 95798-9725
In person: We have trained Certified Enrollment
Counselors and Certified Insurance Agents who can
help you. Or you can visit your county social services
office. This help is free!
For a list of Certified Enrollment Counselors and
Certified Insurance Agents near where you live or
work, or a list of county social services offices near
you, visit CoveredCA.com or call 1-800-300-1506
(TTY: 1-888-889-4500).
33
CCFRM604 (11/13) EN
34
¿Preguntas?
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.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m.
O visite CoveredCA.com.
Extra help may be available
CalFresh
Do you need help buying food for you and your family? CalFresh may be able
to help!
In California, the federal Supplemental Nutrition Assistance Program (SNAP)
is known as CalFresh. CalFresh helps you pay for nutritious fruits, vegetables,
and other healthy foods.
To see if you quality for CalFresh, call 1-877-847-3663 or visit www.calfresh.ca.gov,
or apply online at benefitscal.org.
Welltopia by DHCS
Visit Welltopia by the Department of Health Care Services (DHCS), the place
of wellness, on Facebook and Twitter! You’ll find tips to lower stress, eat healthier
food, enjoy physical activity, quit smoking, and more.
Welltopia by DHCS has:
Free, fun health apps
Cool videos
Links to:
• Tasty and easy recipes
• Farmers’ market locations
“Like” Welltopia by DHCS on Facebook!
• CalFresh
Go to: facebook.com/DHCSWelltopia
Fun places and activities for you and your kids
Education, job placement, and other services
Follow us! @WelltopiaDHCS
to make your life a little easier
Earned Income Tax Credit (EITC)
EITC is a benefit for working people who have low to moderate income. This tax credit reduces the amount of
tax you owe and may also result in a refund.
www.eitc.ca.gov
Child Tax Credit
This tax credit that may be worth as much as $1,000 per qualifying child, depending on your income.
www.childtaxcredit.ca.gov
Getting help in other languages
You can get help with this application in other languages. Call 1-800-300-1506.
Podemos ayudarle en español a llenar
esta solicitud. Llame al 1-800-300-0213.
SPANISH
Quý vị có thể được trợ giúp về
đơn đăng ký này bằng tiếng Việt.
Hãy gọi 1-800-652-9528.
VIETNAMESE
1-800-738-9116.
Maaari kang kumuha ng tulong
para sa aplikasyong ito sa Tagalog.
Tumawag sa 1-800-983-8816.
TAGALOG
Koj txais tau kev pab nrog kev tso npe
no ua lus Hmoob. Hu 1-800-771-2156.
HMONG
1-800-778-7695.
1-800-996-1009.
.1-800-826-6317
“Like” Covered California on Facebook!
Follow us! @CoveredCA
Go to: Facebook.com/CoveredCA
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Application for Health Insurance Your destination for affordable (Covered California)

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Completed 1 February 2022

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