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Get NH DHHS DFA Form 800MA 2018

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 family of 4 Who can use this application Apply even if you or your child already has health coverage. You could be eligible for lower-cost or free coverage If you re single you may be able to use a short form* Visit HealthCare. gov Families that include immigrants can apply. You can apply for your child even if you aren t eligible for coverage. Applying won t affect your immigration status or chances of becoming a permanent resident or citizen If someone is helping you fill out this application you may need to complete Appendix C Apply faster online THINGS TO KNOW What you may need to apply Why do we ask for this information What happens next Get help with this Go to HealthCare. gov or nheasy. nh. gov* Social Security numbers or document numbers for any legal immigrants who need insurance Employer and income information for everyone in your family for example from paystubs W -2 forms or wage and tax statements Policy numbers for any current health insurance Information about any job-related health insurance available to your family We ask about income and other information to let you know what coverage you qualify for and if you can get any help paying for it. We ll keep all the information you provide private and secure as required by law. Send your complete signed application to Central Medicaid Unit 129 Pleasant Street Concord NH 03301. If you don t have all the information we ask for sign and submit your application anyway. We ll follow-up with you within 1 2 weeks You ll get instructions on the next steps to complete your health coverage. If you don t hear from us visit HealthCare. gov or call 1-800- 852-3345 ext. 9700. Filling out this application doesn t mean you have to buy health coverage Online HealthCare. gov Phone Call Client Services at 1-800- 852-3345 ext. 9700 In person There may be counselors in your area who can help* Call 1-800- 852-3345 ext. 9700 for more information En Espanol Llame a nuestro centro de ayuda gratis al 1-800- 852-3345 ext. 9700 You can apply for additional programs by completing a few more questions insert to your local District Office.

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