Forms

Here you can find essential forms designed to facilitate various aspects of your health care coverage. For example, the Request for Health Insurance and Premium Assistance form is for individuals seeking premium reimbursement to offset the costs of their existing health insurance premiums. The Authorized Representative Identity Verification Form serves as a tool for designating someone to act on your behalf. This can be particularly useful in instances where you may need assistance in managing or navigating your health plan.

If you have any questions contact Customer Service at (855) 355-5777.

LDSS-4279

Notice of Responsibilities and Rights for Support

Download Form
LDSS-4882

Child Support Services And Application/Referral For Child Support Services

Download Form
DOH-5106

Request for Health Insurance and Premium Assistance

Download Form
DOH-5085

Authorized Representative Designation

Download Form
DOH-5087

Authorized Representative Identity Verification

Download Form
DOH-5231

Appeal Request

Download Form
DOH-5232

Appoint a Representative for My Appeal

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Important Information Before You Apply

Children can apply for coverage any time during the year. Low-income adults who may be eligible for Medicaid or the Essential Plan can also apply at any time during the year. (Visit here to see if you are eligible.)

Other individuals and families can apply for coverage in a Qualified Health Plan only during Open Enrollment Period which begins November 1 every year, unless they have a life event, such as loss of coverage, marriage or birth of a child, that qualifies them for a Special Enrollment Period. Individuals must apply within 60 days of the Qualifying Life Event.

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Important Information Before You Apply

Children can apply for coverage any time during the year. Low-income adults who may be eligible for Medicaid or the Essential Plan can also apply at any time during the year. (Visit here to see if you are eligible.)

Other individuals and families can apply for coverage in a Qualified Health Plan only during Open Enrollment Period which begins November 1 every year, unless they have a life event, such as loss of coverage, marriage or birth of a child, that qualifies them for a Special Enrollment Period. Individuals must apply within 60 days of the Qualifying Life Event.

Continue