Healthcare Coverage Templates

This form is filed when applying for the Exceptional Family Member Program (EFMP). This form serves as a summary of health condition and needs of that family member and plays a role in the personnel assignment process.

This document is used for applying for Cobra election.

This form is used for reporting Medi-Cal status in California for individuals who speak Tagalog.

This form is used for providing proof of acceptable citizenship or identity documents for California residents of Hmong descent.

This Form is used for acknowledging the receipt of COBRA rights, which provide employees with the right to continue their health insurance coverage after leaving their job or experiencing certain life events.

This document is used to affirm eligibility for TRICARE for Life benefits for veterans.

Medicare is a federal health insurance program in the United States that provides coverage to individuals who are 65 years or older, as well as certain younger individuals with disabilities.

Medicaid is a joint federal and state program in the United States that provides health coverage to low-income individuals and families, including pregnant women, children, and people with disabilities.

This document is used to request a review or appeal of health care services in the state of Delaware. It allows individuals to contest decisions regarding their medical treatments or insurance coverage.

This document is for renewing a Medical Discount Plan (MDP) license in Connecticut.

This Form is used for requesting prior approval in Illinois. It provides instructions for completing the Form HFS1409.

This Form is used for enrolling in Special Needs Basiccare (SNBC) in Minnesota.

This type of document provides information about the cost participation requirements for families in Missouri, specifically for Somali speakers.

This is an IRS legal document completed by individuals who need to figure out the amount of their Premium Tax Credit and reconcile it with the Advanced Premium Tax Credit (APTC) payments made throughout the reporting year.

This document explains the Medicaid Spenddown/Surplus program in New York. It outlines how individuals can qualify for Medicaid by spending down their excess income or assets.

This Form is used for declaring your health care coverage in Vermont.

This form is used for applying for medical benefits through mail in the state of Illinois.

This document is used for Point of Service (POS) in Illinois. It pertains to a healthcare plan that allows participants to choose their own doctors and specialists.

File this renewal form annually in order to renew your Medicare coverage.

This document is used for applying for Senior Rx or Disability Rx programs in Nevada.

This Form is used for requesting authorization for Makena medication under Fee for Service Medicaid in Texas.

This form is used for applying for Medicaid coverage in Texas for individuals who had coverage in the past.

This form is used to calculate income for medical programs in Texas. It helps determine eligibility for Medicaid and other healthcare assistance programs.

This Form is used for providing a notice regarding the Medicare Savings Program in Texas.

This form is used for applying for Medicaid in Texas specifically for breast and cervical cancer patients.

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.

This form is used for documenting the findings related to Form H1852 in the state of Texas.