Health Coverage Templates

This form is used for applying for health coverage and financial assistance in West Virginia.

This document is an application for health coverage and financial assistance for individuals residing in Wyoming. It helps residents access affordable health insurance options and determine if they are eligible for financial support to help cover the costs.

This application is a legal document used to apply for and enroll in Marketplace health coverage with the DHHS.

This form is used for notifying individuals in Texas about their potential eligibility for the Medicaid Buy-In program.

This form is used to apply for the Medicaid Buy-In program for children in Texas.

This document provides a reference chart for the Special Enrollment Periods under the Health Reform. It helps individuals understand when they may be eligible to enroll in health insurance outside of the regular open enrollment period.

This document provides information about health insurance continuation for residents of Dekalb County, Illinois, under the Consolidated Omnibus Budget Reconciliation Act (COBRA) or Health Insurance Continuation under Illinois Insurance Code Section 367j. It outlines the rights and options available for individuals who have lost or are losing their health insurance coverage.

This document provides information about the new health insurance marketplace coverage options and how they may affect your current health coverage. It explains the benefits and enrollment process for these new options.

This form is used for enrolling in the Montana Voluntary Employees' Beneficiary Association (VEBA) program.

This Form is used for requesting information related to Medi-Cal in the Hmong language in the state of California.

This document provides essential information for employees about their health benefits under COBRA. It covers topics such as eligibility, coverage duration, and the rights and responsibilities of employees.

This form is also known as the healthcare marketplace tax form. It is used to inform the IRS about individuals and families enrolled in a health plan via the Health Insurance Marketplace.

Use this document, otherwise known as the IRS Health Coverage Form, for submitting a report to the Internal Revenue Service (IRS) and to taxpayers about individuals with minimum essential coverage who are not liable for the individual shared responsibility payment.

Use this form if you are an insurance provider and wish to inform the IRS about taxpayers who are eligible to receive minimum essential health coverage that meet the standards of the Affordable Care Act.

This form is used for requesting reimbursement for medical expenses incurred in British Columbia, Canada.

This form is used for applying for medical assistance in Pennsylvania for workers with disabilities.

This document is a checklist for residents of Rhode Island who are applying for Medicaid or health coverage assistance. It provides a list of the documents and information that individuals will need to gather and submit as part of their application.

This document is a notice informing individuals in South Carolina about an extension of their COBRA continuation coverage. COBRA allows people to maintain their health insurance coverage after certain qualifying events, such as job loss or reduction in work hours.

This document is for understanding Medicare coverage outside of the United States. It provides information on what medical services are covered and the limitations of coverage when traveling or living abroad.

This form is used for reporting potential overpayments in Medi-Cal, California's Medicaid program. It is specifically for reporting income or other health coverage that may affect eligibility or payment calculations in the Medi-Cal program.

This Form is used for applying for health coverage and financial assistance in Ohio.

This Form is used for requesting an appeal for a healthcare decision in Arizona.

This form is used for applying for health coverage and financial assistance in Missouri. It helps individuals and families with the costs of health care.

This document is used for enrolling in a universal group outside of the Idaho Exchange in Idaho.

This document provides information about health coverage options available to employees in the state of New Mexico. It outlines the various plans and benefits offered and explains how employees can enroll and access these benefits.

This form is used for individuals in Pennsylvania to register as an exchange assister.