Signature Date mm/dd/yyyy STEP 6 Mail completed application. Mail your signed application to CMU 129 Pleasant Street Concord NH 03301 Fax your signed application to CMU Call in your application to Client Services 603 271-8604 603 271-9700 or toll free 1-800-852-3345 ext. 9700 If you are filling out DFA Form 800MA Insert you must send all pages of this application including the insert to your local District Office. NH Department of Health and Human Services DHHS Division of Family Assistance DFA DFA Form 800MA 01/14 Application for Health Coverage Help Paying Costs Use this application to see what coverage choices you qualify for Affordable private health insurance plans that offer comprehensive coverage to help you stay well A new tax credit that can immediately help pay your premiums for health coverage Free or low-cost insurance from Medicaid or the Children s Health Insurance Program CHIP You may qualify for a free or low-cost program even if you earn as much as 94 000 a year for a ....
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How to fill out the NH DHHS DFA Form 800MA online
This guide provides comprehensive instructions for completing the NH DHHS DFA Form 800MA online, ensuring users can efficiently apply for health coverage and assistance. Follow the outlined steps to navigate each section of the form with ease.
Follow the steps to effectively complete your application.
- To start the process, click the ‘Get Form’ button to obtain the NH DHHS DFA Form 800MA and open it in your editor of choice.
- Begin by entering your personal information in Step 1. You'll need to fill in your first, middle, and last name, along with your mailing address, phone number, and email address if applicable.
- Proceed to Step 2. List all family members living with you, including their relationships to you, birth dates, and Social Security numbers where applicable.
- For each family member, provide necessary details about income and employment, including employer name, wages, and hours worked. Ensure that you include all regular sources of income.
- Inquire if any members have existing health coverage and provide relevant details about this coverage in Step 4.
- Complete the signature section in Step 5 to confirm that all submitted information is accurate. If necessary, ensure any Authorized Representatives also sign.
- Finally, save your changes, then download, print, or share the completed form as required for submission to the Central Medicaid Unit or local District Office.
Complete your NH DHHS DFA Form 800MA online today to apply for health coverage!
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