Free Medical Benefits Application Forms and Templates

94
total templates

If you need to reduce the costs associated with common medical occurrences or deal with expenses in the event of an accident, injury, or chronic illness, consider completing a Medical Benefits Application. In times of medical emergencies, proper health coverage provides people with a financial backup along with preventive care – check-ups, screenings, and vaccines. In addition, health insurance will cover the cost of ambulance transportation, hospitalization, surgeries, physical therapy, and prescription drugs. 

How to Apply for Medical Benefits?

Whether you are a self-employed individual, a member of a multi-person household, or a former servicemember in need of medical care, the documents below are the first step to help you stay well and keep getting essential care. Your lifelong health problems will be dealt with, you will reduce the medical costs without depleting your savings when tackling health emergencies, and you may even receive an income tax benefit. 

  1. Once you find an insurance plan that is right for you and your family members, you can file a Health Insurance Application with local authorities to enroll. The information you provide on the health care benefits application – the size of your family, your employment and medical history, income and assets you own – will help the insurance provider to make sure you get the most benefits possible.
  2. Fill out an Application for Health Coverage & Help Paying Costs to apply for Health Insurance Marketplace coverage. You need to provide information about yourself and the members of your household, including employment history, income, and insurance you currently have. The amount of assistance or type of program you qualify for, such as a new private health insurance plan or tax credit to pay the premiums for health coverage, will be decided by the Department of Health and Human Services based on the number of the members in your household and your income. 
  3. Complete a Medicaid Renewal Form to resume your Medicaid membership. When it is time to renew your health insurance plan, you will need to confirm you are still eligible for Medicaid and update contact information and other details if necessary. Your local human services agency will send you the form that you fill out and mail along with any documents the form requests. 

How to Apply for Medical Benefits From the VA?

File the VA Medical Benefits Application (VA 10-10EZ) if you want to apply for enrollment in the VA health care system, domiciliary and dental benefits, or nursing home care. Any veteran – an individual who served in the active military, air, or naval service and was discharged from service - can complete VA Form 10-10EZ to provide the VA with information that determines this veteran’s eligibility for medical benefits.


Check out these related forms:

Documents

94

VA Form 10-10EZ "Application for Health Benefits"

Rate (4.5 / 5) 65 votes
Size: 1 MB
5 pages

The information provided on this form is used by the VA to determine eligibility for certain medical benefits.

Sample "Medicaid Renewal Form"

Rate (4.8 / 5) 12 votes
Size: 235 KB
13 pages

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

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

Rate (4.7 / 5) 11 votes
Size: 357 KB
23 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-53 "Application for Medicaid and Insurance Affordability Programs (Financial Assistance)" - Nebraska

Rate (4.5 / 5) 24 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-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

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

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

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

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

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

Form HSD100 "Application for Assistance" - New Mexico

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