Health Insurance Application Forms by State

92
total templates

Health Insurance is a type of insurance that covers a policyholder’s medical expenses. Insurance coverage of this type can include surgical expenses, dental expenses, and some other types of expenses dedicated to medical issues such as disabilities, illnesses, traumas, accidents, etc. 

How to Apply for Health Insurance?

To get health insurance an applicant needs to conduct research and choose a plan from the variety of options offered on the market. Plans can differ from each other depending on the initial payment and cases that they cover. There can also be different limitations and circumstances when the insurance will be invalid. After a filer chooses their plan they need to fill out a Health Insurance Application

State Health Insurance Application Forms

An Application for Health Insurance is a document that a prospect policyholder must fill out in order to apply for health insurance. Most of them require an applicant to provide information, such as their full name, social security number, current address, data about members of their household, information about their job and income, etc. In most states, the applicant can submit their application by mail or online.

The content of the application also depends on the state where it was released, since states can add some unique features to them. Select your state from the list below to file a Health Insurance Application Form and apply for your state's health care coverage.

Alabama Hawaii Massachusetts New Mexico South Dakota
Alaska Idaho Michigan New York Tennessee
Arizona Illinois Minnesota North Carolina Texas
Arkansas Indiana Mississippi North Dakota Utah
California Iowa Missouri Ohio Vermont
Colorado Kansas Montana Oklahoma (federal form) Virginia
Connecticut Kentucky Nebraska Oregon Washington
Delaware Louisiana Nevada Pennsylvania West Virginia
Florida Maine New Hampshire Rhode Island Wisconsin
Georgia Maryland New Jersey South Carolina Wyoming

Health Insurance Marketplace Application

Fill out the Application for Health Coverage & Help Paying Costs to apply for Health Insurance Marketplace coverage with the Department of Health and Human Services (DHHS). The form requires information about yourself and the members of your household, including employment history, income, and insurance you currently have.

The amount of assistance and the type of program you qualify for will be decided by the DHHS based on the number of your dependents and your income. 


Check out these related forms and topics:

Documents

92

Form DFA-SLA-1 "Application for Health Coverage & Help Paying Costs" - West Virginia

Rate (4.7 / 5) 11 votes
Size: 357 KB
23 pages

Form DFA-SLA-2 "Application for Health Coverage & Help Paying Costs (Short Form)" - West Virginia

Rate (4.8 / 5) 17 votes
Size: 221 KB
14 pages

Form DFA-SLA-S1 "Supplement to Application for Health Coverage" - West Virginia

Rate (4.6 / 5) 16 votes
Size: 98 KB
4 pages

Form W-1E "Application for Benefits" - Connecticut

Rate (4.7 / 5) 43 votes
Size: 1 MB
22 pages

Form KHBE-I11 "Health Coverage & Help Paying Costs - Application for One Person" - Kentucky

Rate (4.7 / 5) 7 votes
Size: 1 MB
5 pages

Form APP10 "Application for Mainecare Benefits" - Maine

Rate (4.3 / 5) 15 votes
Size: 1 MB
12 pages

Form OFI NHW01 "Application for Long Term Care Mainecare" - Maine

Rate (4.4 / 5) 54 votes
Size: 1 MB
12 pages

Form MILTC-64 "Application for Nebraska Medicaid for Aged and Disabled" - Nebraska

Rate (4.4 / 5) 17 votes
Size: 406 KB
11 pages

Form MILTC-53 "Application for Medicaid and Insurance Affordability Programs (Financial Assistance)" - Nebraska

Rate (4.5 / 5) 24 votes
Size: 1 MB
12 pages

Form MILTC-51 "Step 2: Extra Persons in Household Current Job and Income Information" - Nebraska

Rate (4.6 / 5) 34 votes
Size: 242 KB
2 pages

Form DE-103 "Application for Ahcccs Health Insurance and Medicare Savings Programs" - Arizona

Rate (4.3 / 5) 10 votes
Size: 469 KB
17 pages

Form DCO-152 "Household Health Coverage Application" - Arkansas

Rate (4.4 / 5) 17 votes
Size: 1 MB
12 pages

Form DCO-151 "Application Form for Health Coverage Single Adults" - Arkansas

Rate (4.5 / 5) 6 votes
Size: 454 KB
4 pages

Formulario CCFRM604 "Solicitud De Seguro De Salud" - California (Spanish)

Rate (4.6 / 5) 7 votes
Size: 1 MB
36 pages

Form CCFRM604 "Application for Health Insurance" - California

Rate (4.5 / 5) 19 votes
Size: 2 MB
36 pages

Formulario W-1ES "Solicitud De Beneficios" - Connecticut (Spanish)

Rate (4.6 / 5) 39 votes
Size: 1 MB
22 pages

Form 403 "Application for Health Insurance" - Delaware

Rate (4.7 / 5) 27 votes
Size: 107 KB
4 pages

Form 94A "Application for Health Coverage & Help Paying Costs" - Georgia (United States)

Rate (4.7 / 5) 6 votes
Size: 1 MB
9 pages

Formulario 94A "Solicitud Para Cobertura De Salud Y Ayuda Pagando El Costo" - Georgia (United States) (Spanish)

Rate (4.8 / 5) 21 votes
Size: 1 MB
10 pages

BHSF Form 1-A "Application for Health Coverage" - Louisiana

Rate (4.8 / 5) 18 votes
Size: 1 MB
24 pages

Form DOM-300 "Application for Mississippi Medicaid Aged, Blind and Disabled Medicaid Programs" - Mississippi

Rate (4.4 / 5) 21 votes
Size: 486 KB
15 pages

Form DPHHS-HCS-250 "Application for Assistance" - Montana

Rate (4.3 / 5) 11 votes
Size: 1 MB
19 pages

BFA Form 800 "Application for Assistance" - New Hampshire

Rate (4.6 / 5) 18 votes
Size: 488 KB
4 pages

BFA Formulario 800 "Solicitud De Asistencia" - New Hampshire (Spanish)

Rate (4.4 / 5) 19 votes
Size: 144 KB
6 pages

Form HSD100 "Application for Assistance" - New Mexico

Rate (4.3 / 5) 67 votes
Size: 419 KB
27 pages

Formulario HSDSP100 "Solicitud De Asistencia" - New Mexico (Spanish)

Rate (4.4 / 5) 31 votes
Size: 1 MB
31 pages

Form SFN958 "Health Care Application for the Elderly and Disabled" - North Dakota

Rate (4.8 / 5) 19 votes
Size: 2 MB
12 pages

Form DSS-EA-240 "Application for Resource Assessment, Long Term Care or Related Medical Assistance" - South Dakota

Rate (4.4 / 5) 23 votes
Size: 1 MB
22 pages

Form CF-ES2337 "Access Florida Application" - Florida

Rate (4.7 / 5) 22 votes
Size: 3 MB
18 pages

Form DH3212 "Health Insurance Application for Extended Family Planning Benefits" - Florida

Rate (4.6 / 5) 9 votes
Size: 31 KB
2 pages

Form CF-ES2282 "Medicaid/Medicare Buy-In Application" - Florida

Rate (4.5 / 5) 22 votes
Size: 241 KB
3 pages

Form DHS1100 "Application for Health Coverage & Help Paying Costs" - Hawaii

Rate (4.3 / 5) 22 votes
Size: 3 MB
20 pages

Form HW2014 "Application for Health Coverage Assistance" - Idaho

Rate (4.5 / 5) 91 votes
Size: 1 MB
18 pages

Form KC1100 "Application for Medical Assistance for Families With Children" - Kansas

Rate (4.6 / 5) 21 votes
Size: 1 MB
16 pages

Form KC1500 "Application for Medical Assistance for the Elderly and Persons With Disabilities" - Kansas

Rate (4.4 / 5) 20 votes
Size: 1 MB
16 pages

Form DHR/FIA CARES9701 "Application for Assistance" - Maryland

Rate (4.4 / 5) 27 votes
Size: 423 KB
17 pages

Formulario DHR/FIA CARES9701 "Solicitud Para Asistencia" - Maryland (Spanish)

Rate (4.5 / 5) 13 votes
Size: 1 MB
16 pages

Form DCH-1426 "Application for Health Coverage & Help Paying Costs" - Michigan

Rate (4.8 / 5) 12 votes
Size: 1 MB
16 pages

Form DOH-4220 "Health Insurance Application" - New York

Rate (4.7 / 5) 55 votes
Size: 3 MB
15 pages

Form DMA-5200 "Application for Health Coverage & Help Paying Costs" - North Carolina

Rate (4.6 / 5) 7 votes
Size: 1 MB
21 pages