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 _______________________________________________________