Get Pre Existing Conditions Form

Completing the Pre Existing Conditions Form online can streamline your application process for health insurance. This guide will provide you with step-by-step instructions to ensure you accurately fill out the necessary fields and sections.

Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by reviewing Section A, which asks you to indicate the category of individuals you are applying for. Check all that apply, including yourself, spouse, or children under 19.
3. In Section B, provide your personal information. Fill in your last name, first name, middle initial, maiden name, address, phone number, date of birth, and gender. You also have the option to specify your racial and ethnic background.
4. Proceed to Section C, where you will provide information about the individuals needing health coverage. List their names, relationships to you, social security numbers, dates of birth, genders, and whether they have any earnings or disabilities.
5. In Section D, list other household members who live with you but are not applying for health insurance. For each person, include their name, date of birth, and relationship to you.
6. Section E requires that you agree to cooperate with the Child Support Division if you are applying for health coverage for a child. Indicate your agreement and provide details about any non-custodial parents.
7. Complete Section F by providing income details for anyone listed in Sections C and D who receives earned income. Include employer information, hours worked, and pay details.
8. Fill out Section G regarding any other types of income, including child support or unemployment compensation. List the income type, amount, and frequency.
9. If applicable, complete Section H on daycare expenses, providing the necessary details about the care received and payments made.
10. Section I addresses current health insurance coverage. If anyone has existing coverage, fill in the details about the insurance company and policy numbers.
11. For individuals who are not U.S. citizens, Section J asks for immigration details. Provide the necessary information regarding immigration status and entry.
12. In Section K, indicate if any individuals are members of federally recognized American Indian tribes, as this may affect premium costs.
13. Finally, carefully read Section L, which includes terms and conditions. Sign and date the form. If someone assisted you, their signature should be included as well.
14. Once all sections are completed, save your changes. You can then download, print, or share the completed form as needed.

Start your application today by filling out the Pre Existing Conditions Form online.