Citizen 6765 Manual do Utilizador descarregar pdf

Visit MAhealthconnector.org or call 1-877 MA ENROLL (1-877-623-6765)

TTY: 1-877-623-7773, Monday to Friday, 8:00 a.m. to 6:00 p.m.

Questions?

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Application for

Health and Dental

Insurance Coverage

Who can use this

application?

Use this application for youself and anyone in your tax household who

needs health or dental insurance coverage. People in your tax household

could include a spouse, child under the age of 27, or a child over the age

of 26 if they have a disability.

Apply faster online.

Apply faster online at MAhealthconnector.org.

Get help with

this application:

 Visit MAhealthconnector.org.

 Call our Customer Service at 1-877 MA ENROLL (1-877-623-6765) or

TTY: 1-877-623-7773.

 In person: there may be counselors in your area who can help.

Visit MAhealthconnector.org for more information.

 En Español: Llame a nuestro centro de ayuda gratis al

1-877 MA ENROLL (1-877-623-6765).

 If you need help in a language other than English, call 1-877 MA ENROLL

(1-877-623-6765) and tell the Customer Service Representative the

language you need. We’ll get you help at no cost to you.

If someone is helping you ll out this application, you may need

to complete Appendix A.

Sending the application:

Send your complete, signed application to:

Massachusetts Health Connector

133 Portland Street, 1st Floor

Boston, MA 02114-1707

or fax to 877-623-2155.

Filling out this application doesn’t mean you have to buy health coverage.

Get help paying

for insurance:

You need to use a different application to get help with costs.

You could qualify for:

 A new tax credit that can help pay your premiums for health

insurance coverage.

 Free or low-cost health insurance plan 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 $94,200 a

year (for a family of 4). Visit MAhealthconnector.org to learn more.

If you’re not sure what you qualify for, go to MAhealthconnector.org

and apply online.

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Página 1 - Insurance Coverage

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Página 2 - Questions?

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Página 3

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Página 4

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Página 6

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Citizen 6765 Manual do Utilizador

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