Visit MAhealthconnector.org or call 1-877 MA ENROLL (1-877-623-6765)
or
TTY: 1-877-623-7773, Monday to Friday, 8:00 a.m. to 6:00 p.m.
Questions?
2 of 7
STEP 1
Tell us about yourself.
Choose one adult in the family to be the contact person for your application.
PERSON 1
Please be sure to answer all questions and ll out all parts of this application.
First name Middle name Last name Sufx
Home address (Not PO box) Check here
if you are homeless.
Unit or apartment number
City State ZIP code
Mailing address Check here
if same as home address.
Unit or apartment number
City State ZIP code
Best phone number
Home
Work
Cell Other phone number
Home
Work
Cell
Email address:
Do you want to get information about this application by email?
Yes
No
Language you prefer to speak (if not English) Language you prefer to write (if not English)
Do you need health coverage?
Yes
No
Do you need dental coverage?
Yes
No
If yes, have you had dental insurance within the last 12 months?
Yes
No
If you need health or dental coverage, answer all the questions below. If not, go to Step 2 on page 3.
Social Security number (SSN): ___ ___ ___ /___ ___ /___ ___ ___ ___
We need Social Security numbers (SSNs) for anyone who wants coverage. We use SSNs to verify
citizenship. If someone doesn’t have an SSN, visit socialsecurity.gov or call 1-800-772-1213.
Are you
Male
Female
Date of birth (month/day/year)
Are you a U.S. citizen or U.S. national?
Yes
No
If you are not a U.S. citizen or U.S. national, are you lawfully present in the U.S.?
Yes
No
If yes, write your immigration document type ______________________________________________________
For more information on acceptable immigration documents, go to MAhealthconnector.org
and write your immigration document ID number _____________________________________________________________
Are you living in Massachusetts?
Yes
No
If yes, do you plan to stay in Massachusetts?
Yes
No
If no, are you planning to move to Massachusetts?
Yes
No
Are you in jail or prison?
Yes
No If yes, are you (check one below)
Convicted. What is your expected release date? (month/day/year) ___ ___ /___ ___ /___ ___ ___ ___
Not convicted. (For example: conned only, awaiting trial)
(14 strony)
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