Application for

Health Care Coverage

(and to find out if you can get help with costs)
Use this application to see Free or low-cost health care coverage from Washington Apple Health
•
what health care coverage (Medicaid), including the Children’s Health Insurance Program (CHIP)
you qualify for: • A tax credit that can help you pay your health care premiums for a
Qualified Health Plan
• Full-cost private Qualified Health Plan and Qualified Dental Plan
Apply faster online Apply faster online at www.wahealthplanfinder.org
Information you will need • Social Security numbers
to apply: • Birthdays
• Foreign passport, “A” number, or other immigration numbers for
any immigrants applying for health care coverage
• Income information for all adults and all minors who are required
to file a tax return
• Information about health insurance available to your family
Why do we ask for so much We need the following information in order to determine what health
information? care coverage you qualify for. We will keep the information you provide
private as required by law.
Send your complete and Washington Healthplanfinder
signed application to: PO Box 946
Olympia, Washington, 98507
or Fax 1-855-867-4467
If you don't have all the information we ask for, you can start your
application by filling in your name, date of birth, signature, and address
and mail to the address above.
Get help with this • Online: www.wahealthplanfinder.org
application: • Phone: Call the Customer Support Center at
1-855-WAFINDER (855-923-4633) or 1-855-627-9604 (TTY)
• In person: To get application assistance search for a Navigator or
Broker via the customer support link at
www.wahealthplanfinder.org.
• Language or disability: To get free help in your language (including
an interpreter or translation of printed materials) or a
disability accommodation, call 1-855-WAFINDER (855-923-4633) or
1-855-627-9604 (TTY)

i
Definitions
Health Insurance Premium Tax Credits: Tax credits can be used to lower your monthly premium, the
amount you pay each month for your health plan.
Washington Healthplanfinder: An online marketplace for individuals, families and small businesses in
Washington to compare and enroll in coverage and gain access to tax credits, reduced cost-sharing, and
public programs such as Washington Apple Health.
Premium: The amount you pay each month for your health plan. You must pay your premium even if you
do not receive any health care services.
Qualified Health Plan: Private health coverage through Washington Healthplanfinder.

Minimum Essential Coverage: This is the type of coverage an individual needs to have to meet the
individual responsibility requirement under the Affordable Care Act. This includes individual market
policies, job-based coverage, Medicare, Medicaid, Children's Health Insurance Program (CHIP), TRICARE
and other coverage that covers the 10 Essential Health Benefits.
Essential Health Benefits: A set of 10 health care services that all plans must cover, like doctor visits,
hospital stays, and prescription drug. Some benefits are free, and some may have co-pays and co-
insurance.
Washington Apple Health: The public health insurance programs for eligible Washington residents.
Washington Apple Health is the name used in Washington for Medicaid, the Children's Health Insurance
Program (CHIP), and state-only funded health care programs.

For people who are self-employed

You can subtract the allowable expenses below from your gross income to get an amount for your net
self-employment income. For more information, see “Instructions for Schedule C or Schedule F” at
www.irs.gov.
Some examples of allowable expenses are:

• Car and truck expenses

• Commissions, fees, and contract labor
• Depletion
• Depreciation
• Employee benefit programs, pension, and profit-sharing plans
• Insurance (except health) and mortgage interest
• Legal and professional services
• Office expenses, rent, and lease
• Property, liability, or business interruption insurance
• Supplies, repairs, and maintenance
• Travel, meals, and entertainment
• Utilities, taxes, and licenses
• Wages (less employment credits)

ii
Health Care Coverage Rights and Responsibilities
Your rights (we must) a case review, you will be scheduled an
for all health care coverage programs Administrative Hearing.
Help you read and fill out all requested forms. Treat you fairly. Discrimination is against the
For assistance you can contact Washington law. The Washington Health Benefit
Healthplanfinder or if you are an individual Exchange/Health Care Authority complies with
who is aged, blind or disabled or in need of applicable Federal civil rights laws and does not
long-term services and supports (LTSS) you can discriminate on the basis of race, color,
contact the Department of Social and Health national origin, age, disability, or sex. The
Services (DSHS). Washington Health Benefit Exchange/Health
Care Authority does not exclude people or
Provide interpreter or translator services at no
treat them differently because of their race,
cost to you and without delay when
color, national origin, age, disability, or sex.
communicating with Washington
The Washington Health Benefit
Healthplanfinder, Health Care Authority or
Exchange/Health Care Authority also complies
DSHS.
with applicable state laws and does not
Keep your personal information private but discriminate on the basis of creed, gender,
we may share some information with other gender expression or identity, sexual
state and federal agencies for purposes of orientation, marital status, religion, honorably
eligibility and enrollment. discharged veteran or military status, or the
Give you the opportunity to appeal if you use of a trained dog guide or service animal by
disagree with a determination made by a person with a disability.
Washington Healthplanfinder or DSHS that The Washington Health Benefit
affects your eligibility for health coverage, LTSS, Exchange/Health Care Authority:
a health plan, health insurance premium tax • Provides free aids and services to
credits, or cost-sharing reductions. By asking people with disabilities so they can
for an appeal, your case will be reviewed. You communicate effectively with us, such
can find more information about the as:
Washington Healthplanfinder appeals process • Qualified sign language interpreters
by visiting the Washington Healthplanfinder • Written information in other formats
Appeals Page at (large print, audio, accessible
http://www.wahbexchange.org/appeals/ or electronic formats, other formats)
contacting the Washington Healthplanfinder • Provides free language services to
Customer Support Center at 1-855-923-4633. people whose primary language is not
For information about appeals for DSHS English, such as:
programs, you may contact DSHS Customer • Qualified interpreters
Service Contact Center at 1-877-501-2233 or • Information written in other
visit your local Home and Community Services languages
Office. If you need these services, contact
If the appeal is for a decision on Washington 1-855-923-4633.
Apple Health coverage, which is unresolved by
iii
If you believe that the Washington Health Your responsibilities (you must)
Benefit Exchange/Health Care Authority has for all health care coverage programs
failed to provide these services or SSN and Immigration Status Disclosure. With
discriminated in another way you can file a some exceptions, you must provide a Social
grievance with: Security Number (SSN) or immigration
• Washington Health Benefit Exchange document number of yourself or anyone else in
Legal Department your household who wants to apply for health
ATTN: Legal Division Equal Access/Equal care coverage. An SSN is required to apply for
Opportunity Coordinator health insurance premium tax credits. We use
PO Box 1757 this information to determine your eligibility by
Olympia, WA 98507-1757 confirming your identity, citizenship,
1-855-859-2512 immigration status, date of birth, and
Fax: 1-360-841-7653 availability of other health care coverage.
[email protected] We do not share this information with any
immigration agency.
• Health Care Authority Division of Legal
It is possible to apply for coverage for some
Services
members of your household, but not others. If
ATTN: Compliance Officer
(ADA/Nondiscrimination Coordinator) you do not have an SSN or immigration
PO Box 42704 document number for all household members,
Olympia, WA 98501-2704 others can still apply for and get coverage. For
1-855-682-0787 example, you can apply for your child even if
Fax: 1-360-507-9234 you aren’t eligible for coverage. Applying won’t
[email protected] affect your immigration status or chances of
becoming a permanent resident or citizen.
You can file a grievance in person or by There are also some Washington Apple Health
mail, fax, or email. If you need help filing a programs for people who cannot show they are
grievance, the Washington Health Benefit in the country legally. But if you choose not to
Exchange Legal Department/Health Care provide an SSN or immigrant document
Authority Division of Legal Services is number for someone in your household, we
available to help you. will need to follow up with you to get
information about the non-applicant's income.
You can also file a civil rights complaint with the
U.S. Department of Health and Human Services, If requested by the agency, provide any
Office for Civil Rights electronically information or proof needed to decide if you
athttps://ocrportal.hhs.gov/ocr/portal/lobby.jsf, are eligible.
or by mail or phone at:
Things you should know
U.S. Department of Health and Human for all health care coverage programs
Services
There are certain state and federal laws that
200 Independence Avenue SW
govern the operation of Washington
Room 509F, HHH Building
Healthplanfinder and state-administered
Washington, D.C. 20201
application systems, your rights and
1-800-368-1019, 800-537-7697 (TDD). responsibilities as someone who uses them and
the coverage you get from using them. By using
Complaint forms are available at
these systems, you agree to comply with the
www.hhs.gov/ocr/office/file/index.html.
laws that apply to someone using them and the
coverage they get as a result.
iv
The National Voter Registration Act of 1973 period, your information will be deleted from
requires all states to provide voter registration the Washington Healthplanfinder system.
assistance through their public assistance Washington Healthplanfinder, HCA and DSHS
offices. are not responsible for administering your
Applying to register or declining to register to health insurance plan. Your health insurance
vote will not affect the services or benefits that carrier can provide you more information
you will be provided by this agency. You can about your benefits.
register to vote at www.vote.wa.gov or If you have questions about the terms of your
order voter registration forms by calling health insurance plan, including what benefits
1-800-448-4881. you are eligible for, out of pocket expenses under
Health Insurance Portability and your plan, and making a benefit claim or
Accountability Act (HIPAA) restrictions prevent appealing a denial of benefits, you should
the Health Care Authority (HCA) and DSHS from contact your health insurance carrier. If you are
discussing the health information of you or any eligible for COBRA following the termination of
member of your household with anyone, any health insurance coverage purchased through
including an authorized representative, unless Washington Healthplanfinder, administering
that individual has power of attorney or you COBRA and providing you the required COBRA
have signed a consent form authorizing the notices and election periods is your employer’s
disclosure of this information. This includes responsibility.
disclosure of mental health information, HIV, Do not cancel any current insurance coverage
AIDS, STD test results, or treatment and or decline any COBRA benefits until you receive
chemical dependency services. an approval letter and insurance policy, also
For more information about Washington known as insurance contract or certificate,
Healthplanfinder’s privacy policy, visit from the insurance carrier you selected. Make
https://www.wahealthplanfinder.org/_content/ sure you understand and agree with the terms
PrivacyPolicy.html of the policy, pay special attention to the
effective date, waiting periods, premium
The Affordable Care Act prevents the
amount, benefits, limitations, exclusions, and
Washington Healthplanfinder and DSHS from
riders.
giving the personally identifiable information
(PII) of you or any member of your household You may apply for support enforcement
to anyone who is not authorized to receive it, services through the Division of Child Support
and without your consent. (DCS).
The information that you give Washington To get an application for these services, go to
Healthplanfinder and DSHS is subject to www.childsupportonline.wa.gov or contact
verification by federal and state officials for your local DCS office.
purposes of determining your eligibility for Your rights (we must)
health care coverage. Verification can include for Washington Apple Health only
follow-up contacts from agency staff.
Explain to you your rights and responsibilities
If you begin completing an application for if you ask.
health insurance through Washington
Healthplanfinder and do not complete the Allow you to submit a partial application that
process for any reason, your information will includes at minimum, your name, address, and
be stored in Washington Healthplanfinder and signature or the signature of the applicant’s
accessible by you for 90 days. If you do not authorized representative. The day we get a
complete an application after the 90-day partial application is your application date,
which may affect when your coverage becomes
v
 effective. We will not make a final decision Read your approval letter to see what
about your coverage until after you complete changes you must report.
the application. Complete renewals when asked.
Allow you to submit an application or partial Give medical providers information
application using any method listed under needed to bill us for health care services.
WAC 182-503-0005.
Apply for Medicare if you are entitled to
Process your application promptly and no later it.
than the timelines described in WAC 182-503-
0060. Cooperate with Quality Assurance staff
when asked.
Give you 10 calendar days to provide
information we need to determine eligibility. If Apply for and make a reasonable effort
you ask for more time, we will give you more to get potential income from other
time. If you don’t give us the information or ask sources when you ask for or receive
for more time, we may deny, close, or change Washington Apple Health coverage.
your health care coverage. Things you should know
Help you if you have trouble getting any for Washington Apple Health only
information or proof needed for us to decide if By asking for and receiving Washington
you are eligible. If we require a document that Apple Health, you give the state of
will cost you money, we will send for it and pay Washington all rights to any medical
the cost. support and to any third party payments
Notify you, in most cases, at least 10 days for health care.
before we stop your health care coverage. The Agency may share your child’s
Give you a written decision, in most cases, immunization history with the Child
within 45 days. Health care coverage for some Profile Immunization Tracking System.
disability cases may take up to 60 days. We give Information you report may be
a written decision on pregnancy medical within provided to DSHS to determine
15 days. eligibility and monthly benefits for
Allow you to refuse to speak to an investigator programs such as health care coverage,
if we audit your case. You do not have to let an cash assistance, food assistance and
investigator into your home. You may ask the child care subsidies.
investigator to come back at another time. By law, the State of Washington may recover
Such a request will not affect your eligibility for the costs it paid for certain types of medical
health care coverage. services from your estate through Estate
Continue Washington Apple Health coverage Recovery (RCW 41.05A.090, RCW 43.20B.080,
while we decide if you are eligible for another and Chapter 182-527 WAC). Estate Recovery
program per WAC 182-504-0125. doesn’t happen until after your death, the
death of your surviving spouse, and your
Give you equal access services as described in surviving children are age 21 or older. It also
WAC 182-503-0120 if you are eligible. doesn’t happen if a surviving child was
Your responsibilities (you must) blind/disabled at your time of death.
for Washington Apple Health only Recoverable costs include:
Report changes as required in WAC 182- • Certain Washington Apple Health long-term
504-0105 and WAC 182-504-0110 within services and supports, if you’re age 55 or
30 days of the change. older at the time you received the services;

vi
 • Certain state-only funded services, responsibility to respond to our request,
regardless of your age at the time you contact us when you have questions, and reply
received the services. before the deadline.
You can find a list of services subject to cost Social Security number (SSN): You are required
recovery under WAC 182-527-2746. You can to give us social security number(s) for
find a list of assets excluded from recovery everyone in your household who has a social
under WAC 182-527-2754.
security number. If someone doesn’t have a
The State may also file a pre-death lien on your social security number, they still may be able to
real property, at any age, if you become get health insurance coverage.
permanently institutionalized (WAC 182-527-
2734). The State may recover from a sale of the Report changes in income immediately: The
property, or your estate, unless: income you put in your application is an
estimate of how much you think you’ll make
• Your spouse lives at the property;
this year. When your income changes, you
• Your sibling lives at the property, is a co-
should update your estimate. A change in your
owner, and meets certain conditions.
income may change your eligibility for tax
• Your child lives at the property, and is
blind/disabled; or credits and that will change your deductibles
• Your child lives at the property and is and cost-sharing reductions. Be as accurate as
younger than age 21. possible when estimating your income and
quickly report all significant changes.
You can find a list of services subject to cost
recovery under WAC 182-527-2734. Reconciling tax credits is required: You are
required to report the tax credits you receive
You may be restricted to one health care
provider, pharmacy, and/or hospital if you seek to the IRS. You do this by filing an annual IRS
out unnecessary health care services from tax return and including the correct IRS forms.
providers. Failure to report tax credits to the IRS will
Things you should know keep you from receiving tax credits in the
for Qualified Health Plans only future. For more information read the
instructions provided with the IRS forms 1095
We verify your information: We confirm the
and 8962.
information on your application with the
federal database. If the information you put on Health insurance costs shown can change:
your application doesn’t match the federal Costs can change based on the health
database, you have 95 days to provide these insurance carrier's underwriting practices and
documents. Failure to respond to our your choice of any available options.
request(s) could result in the termination of
your coverage or tax credits. It’s your

vii
 viii
viii
 Application for Health Care Coverage
PART 1
Primary applicant name and contact information
First name, Middle initial, Last name & Suffix Date of birth (MM/DD/YYYY) Sex M F

Signature of primary applicant or authorized representative (required) Social Security number

X _________________________________________________________
Do you have a home address? No Yes You still need to provide a mailing address.
If no, in what county would you like to receive health care services?
Address where you live City County State ZIP code

Mailing address (If different) City State ZIP code

Primary phone number Secondary phone number E-mail address

Cell Home Work Cell Home Work

Washington Healthplanfinder may need to contact you regarding the status of your application and/or
request additional information. How do you prefer to be contacted?
Phone Email USPS Mail
Language information
Do you or anyone you are applying for want an interpreter and to receive documents in a language
other than English? No Yes If yes, what language or alternative format do you need?
List all that apply:
Pregnancy information
Is someone in the household pregnant? No Yes
HCA 18-001P (10/19)

1
Authorized representative information
1. An authorized representative (AREP) is any adult who is sufficiently aware of the household
circumstances and is authorized by the household to act on behalf of the household for eligibility
purposes. This is different from partnering with a Navigator or a Broker.
2. If an applicant is unable to designate an AREP, due to a medical condition, an individual may
self-designate as the AREP by completing the Authorization Representative Designation Form
(DSHS 14-532) at www.dshs.wa.gov/authorized-rep-form.
3. By designating an authorized representative, you are giving permission for your authorized
representative to:
• Sign the application on your behalf;
• Receive notices related to your application and account; and
• Act on your behalf for all matters related to the application and account.
Are you designating an authorized representative?
a. No Yes
b. Do you want your authorized representative to receive notices related to your application and
account? No Yes
Authorized representative name / organization Phone number

Mailing address of authorized representative E-mail address

Information about your family

You must include these individuals on your application: your spouse, your children who live with you,
all parents living in the home with their child, and anyone you expect to claim on your federal income
tax return, if you file one. (use pages 3 through 7 to share information about your family)

If you expect to be claimed as a tax dependent on someone’s tax return, you must include all members
of the tax filing household claiming you and any family members living with you.

You don’t need to file taxes to apply for health care coverage.

2
Primary applicant (self)
First name M.I. Last name Date of birth
(MM/DD/YYYY)

Is this person applying for health care coverage? Sex M F Relation to you SELF
No Yes
(For individuals not applying for coverage, providing a Social Security number (SSN) or citizenship
status is optional)
Citizen or Non-citizen status: (check one)
U.S. citizen or U.S. national Non-citizen lawfully present in the U.S. Other
Social Security number (SSN):
If you are a lawfully present non-citizen, enter the following information:
Include the document type, your “A” number and receipt number or other immigration number:
Immigration document “A” number: Receipt number or other number:
type:

Foreign passport number: Country of issuance:

Date of entry: Document expiry date:

/ / / /
Expected tax filing status for the current year
(select one) Tax dependent of someone on the application
Single filing taxes Tax dependent of someone not on the
Head of household application
Qualifying widow(er) with dependent child Person has neither filed taxes nor was tax
Married filing separately dependent
Married filing jointly:
Name of primary tax filer:

Did you have the same tax filing status last year as the current year listed above? No Yes
If no, list last year’s tax filing status:
(Your response to this question does not affect your eligibility for Apple Health)
If you are submitting this application between 11/01 and 12/31 of this calendar year, do you expect to
file with the same tax status next year as you do this year? No Yes
RACE / ETHNICITY CODE (OPTIONAL – check all that apply) If American Indian or Alaska Native, do not
enter a race or ethnicity
White Black or African American Asian Native Hawaiian Pacific Islander
Hispanic or Latino Other
Are you an American Indian or Alaska Native? No Yes

3
Spouse or other parent (if living in the home)
First name M.I. Last name Date of birth
(MM/DD/YYYY)

Is this person applying for health care Sex Relation to you (i.e. spouse, domestic
coverage? No Yes M F partner, partner)
(For individuals not applying for coverage, providing a Social Security number (SSN) or citizenship
status is optional)
Citizen or Non-citizen status: (check one)
U.S. citizen or U.S. national Non-citizen lawfully present in the U.S. Other
Social Security number (SSN):
If you are a lawfully present non-citizen, enter the following information:
Include the document type, your “A” number and receipt number or other immigration number:
Immigration document “A” number: Receipt number or other number:
type:

Foreign passport number: Country of issuance:

Date of entry: Document expiry date:

/ / / /
Expected tax filing status for the current year
(select one) Tax dependent of someone on the
Single filing taxes application
Head of household Tax dependent of someone not on the
Qualifying widow(er) with dependent child application
Married filing separately Person has neither filed taxes nor was tax
Married filing jointly: dependent
Name of primary tax filer:
Did you have the same tax filing status last year as the current year listed above? No Yes
If no, list last year’s tax filing status:
(Your response to this question does not affect your eligibility for Apple Health)
If you are submitting this application between 11/01 and 12/31 of this calendar year, do you expect to
file with the same tax status next year as you do this year? No Yes
RACE / ETHNICITY CODE (OPTIONAL – check all that apply)
If American Indian or Alaska Native, do not enter a race or ethnicity
White Black or African American Asian Native Hawaiian Pacific Islander
Hispanic or Latino Other
Are you an American Indian or Alaska Native? No Yes

4
(1.) List children / Tax dependents/Other household members
First name M.I. Last name Date of birth
(MM/DD/YYYY)

Is this person applying for health care Sex Relation to you (i.e. child, grandchild, niece,
coverage? No Yes M F nephew, sibling)
(For individuals not applying for coverage, providing a Social Security number (SSN) or citizenship
status is optional)
Citizen or Non-citizen status: (check one)
U.S. citizen or U.S. national Non-citizen lawfully present in the U.S. Other
Social Security number (SSN):
If you are a lawfully present non-citizen, enter the following information:
Include the document type, your “A” number and receipt number or other immigration number:
Immigration document “A” number: Receipt number or other number:
type:

Foreign passport number: Country of issuance:

Date of entry: Document expiry date:

/ / / /
Expected tax filing status for the current year
(select one) Tax dependent of someone on the
Single filing taxes application
Head of household Tax dependent of someone not on the
Qualifying widow(er) with dependent child application
Married filing separately Person has neither filed taxes nor was tax
Married filing jointly: dependent
Name of primary tax filer:
Did you have the same tax filing status last year as the current year listed above? No Yes
If no, list last year’s tax filing status:
(Your response to this question does not affect your eligibility for Apple Health)
If you are submitting this application between 11/01 and 12/31 of this calendar year, do you expect to
file with the same tax status next year as you do this year? No Yes
RACE / ETHNICITY CODE (OPTIONAL – check all that apply)
If American Indian or Alaska Native, do not enter a race or ethnicity
White Black or African American Asian Native Hawaiian Pacific Islander
Hispanic or Latino Other
Are you an American Indian or Alaska Native? No Yes

5
(2.) List children / Tax dependents/Other household members
First name M.I. Last name Date of birth (MM/DD/YYYY)

Is this person applying for health Sex Relation to you (i.e. child, grandchild, niece,
care coverage? No Yes M F nephew, sibling)
(For individuals not applying for coverage, providing a Social Security number (SSN) or citizenship
status is optional)
Citizen or Non-citizen status: (check one)
U.S. citizen or U.S. national Non-citizen lawfully present in the U.S. Other
Social Security number (SSN):
If you are a lawfully present non-citizen, enter the following information:
Include the document type, your “A” number and receipt number or other immigration number:
Immigration document “A” number: Receipt number or other number:
type:

Foreign passport number: Country of issuance:

Date of entry: Document expiry date:

/ / / /
Expected tax filing status for the current year
(select one) Tax dependent of someone on the
Single filing taxes application
Head of household Tax dependent of someone not on the
Qualifying widow(er) with dependent child application
Married filing separately Person has neither filed taxes nor was tax
Married filing jointly: dependent
Name of primary tax filer:
Did you have the same tax filing status last year as the current year listed above? No Yes
If no, list last year’s tax filing status:
(Your response to this question does not affect your eligibility for Apple Health)
If you are submitting this application between 11/01 and 12/31 of this calendar year, do you expect to
file with the same tax status next year as you do this year? No Yes
RACE / ETHNICITY CODE (OPTIONAL – check all that apply)
If American Indian or Alaska Native, do not enter a race or ethnicity
White Black or African American Asian Native Hawaiian Pacific Islander
Hispanic or Latino Other
Are you an American Indian or Alaska Native? No Yes

6
 (3.) List children / Tax dependents/Other household members
First name M.I. Last name Date of birth
(MM/DD/YYYY)

Is this person applying for health Sex Relation to you (i.e. child, grandchild, niece,
care coverage? No Yes M F nephew, sibling)
(For individuals not applying for coverage, providing a Social Security number (SSN) or citizenship
status is optional)
Citizen or Non-citizen status: (check one)
U.S. citizen or U.S. national Non-citizen lawfully present in the U.S. Other
Social Security number (SSN):
If you are a lawfully present non-citizen, enter the following information:
Include the document type, your “A” number and receipt number or other immigration number:
Immigration document “A” number: Receipt number or other number:
type:

Foreign passport number: Country of issuance:

Date of entry: Document expiry date:

/ / / /
Expected tax filing status for the current year
(select one) Tax dependent of someone on the
Single filing taxes application
Head of household Tax dependent of someone not on the
Qualifying widow(er) with dependent child application
Married filing separately Person has neither filed taxes nor was tax
Married filing jointly: dependent
Name of primary tax filer:
Did you have the same tax filing status last year as the current year listed above? No Yes
If no, list last year’s tax filing status:
(Your response to this question does not affect your eligibility for Apple Health)
If you are submitting this application between 11/01 and 12/31 of this calendar year, do you expect to
file with the same tax status next year as you do this year? No Yes
RACE / ETHNICITY CODE (OPTIONAL – check all that apply)
If American Indian or Alaska Native, do not enter a race or ethnicity
White Black or African American Asian Native Hawaiian Pacific Islander
Hispanic or Latino Other
Are you an American Indian or Alaska Native? No Yes
To include more household members, attach a sheet with the information requested above for each
individual.

7
Information about your household

American Indian & Alaska Native information

American Indian and Alaska Natives may be eligible for special Washington Apple Health (Medicaid)
protections and for special benefits through Washington Healthplanfinder. Complete the table below
for each member you are applying for that is of American Indian or Alaska Native descent.
Member of a federally
recognized tribe, band,
Pueblo or Rancheria;
Name of person Tribe name
Shareholder in an Alaska
Native Regional or Village
Corporation
No Yes
No Yes
No Yes
No Yes
Residency
A Washington resident is someone who currently resides in Washington, intends to reside in
Washington, including individuals without a fixed address; or someone who entered the state with a
job commitment or looking for a job.
Is everyone applying for health care coverage a Washington State resident? No Yes
If no, list anyone who is not a resident:
Tobacco use
Has any household member on this application regularly used tobacco products in the past 6 months?
No Yes
If yes, enter their name:
(Your response to this question does not affect your eligibility for Apple Health)
Adult disabled dependent
An adult disabled child is an individual who is not capable of employment due to a disability and is
dependent on a household member for support.
Do you have an adult child who is a disabled dependent 26 years or older? No Yes
If yes, enter their name:
(Your response to this question does not affect your eligibility for Apple Health)
Jail and prison information
1. Are you or anyone you are applying for in jail or prison? No Yes
2. If yes, enter their name:
3. Are disposition of charges pending? No Yes
4. Is release date within 30 days? No Yes

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Voter registration
If you are not registered to vote where you live now, would you like to apply to register to vote?
No Yes
If you select “Yes” you will be provided a voter registration form.
Applying to register or declining to register to vote will not affect the amount of assistance that you will
be provided or your eligibility.
If you would like help in filling out the voter registration application, you can receive assistance at
Washington’s toll-free voter registration hotline, 1-800-448-4881. The decision whether to seek or
accept help is yours. You may fill out an application in private.
If you believe that someone has interfered with your right to register to vote or to decline to register to
vote, or your right to privacy in deciding whether to register, you may file a complaint with the
Washington State Election Division, PO Box 40229, Olympia, WA 98504, email [email protected],
or call 1-800-448-4881.
Signature for Qualified Health Plan applicants
STOP: You could be eligible for free or low-cost coverage. If you don’t want your income considered
and would like to enroll in a Qualified Health Plan (QHP), sign below and submit your application.
You will pay full cost for your health coverage and do not need to complete Part 2 of the application.
I have read or had explained to me my Rights and Responsibilities.

By signing this application, you are agreeing to Washington Healthplanfinder sharing your information
with other state and federal agencies.

Signature Date
CONTINUE: To apply for Washington Apple Health (Medicaid) or tax credits to lower your insurance
premium, you must complete Part 2 of this application.

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 PART 2
Health insurance information
Do you or anyone you are applying for have health insurance coverage other than Washington Apple
Health (Medicaid or CHIP)?
(Examples include private or employer insurance, Medicare, Veterans, Peace Corps and Tri-Care)
No Yes
If yes, provide the information in the table below. If more than one person has other insurance, use
additional paper.
Policy
Insurance
Policy holder’s / holder’s
company or Policy number Group number
employee's name date of
employer name
birth

List all household members covered under this plan:

Employer-sponsored insurance
Did your employer offer you health insurance coverage? No Yes (if yes, provide employer
information in the table above)
How much would it cost for you to enroll yourself in the lowest priced plan? (don’t include cost for
other family members)
Monthly plan cost: $
How often paid (e.g., bi-weekly, monthly, annually)?
(Your response to this question does not affect your eligibility for Apple Health)
Children’s health insurance
Skip this question and go to the next section (Unpaid medical bill information) if you are not applying
for coverage for a child.
Does your health insurance cover your children? No Yes
If yes, enter child’s name:
Have you dropped health insurance coverage for your children, under age 19, within the last four
months? No Yes
If yes, when did the coverage end?

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Unpaid medical bill information
Do you or anyone you are applying for need help paying for unpaid medical bills for services received in
any of the 3 months immediately before the current month? No Yes
If yes, enter name:
Non-citizen emergency medical information
You or family member may be eligible for limited emergency coverage even if you are not eligible for
other coverage because of your immigration status.
Check all boxes that apply to any non-citizen you are applying for and enter their name in the space
provided
Has been treated for an emergency medical condition this month or during the previous three
months:
Who:
Needs dialysis or cancer treatment: Who:
Needs anti-rejection medication as a result of an organ transplant: Who:
Needs nursing home, assisted living, or in-home care: Who:
Pregnancy information
Are you or anyone in your household pregnant? No Yes (Use the second line if more than 1
person is pregnant.) If yes,
enter name: Due date: Number expected:
enter name: Due date: Number expected:
Gross income information
This section helps us determine the amount of your household’s modified adjusted gross income
(MAGI). MAGI income must be used in order to determine if you are eligible for most health care
coverage programs. Please answer the following questions for each household member you are
applying for as accurately as you can. Only enter information about the type of income listed.
You will need to enter current gross monthly income information for yourself, your spouse and any
minors and tax dependents regardless of age, unless the minor or tax dependent will not be required
to file taxes. For more information about how to report income, visit www.wahbexchange.org/how-
to-report-income
Note: American Indians/Alaska Natives (AI/AN) do not have to report any AI/AN income that the
Internal Revenue Service excludes from an AI/AN’s taxable gross income. In addition, AI/ANs do
not have to report certain types of income for Washington Apple Health (Medicaid) as described in
WAC 182-509-0340.

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Income from a job: Are you or anyone you are applying for currently employed? No Yes
If yes, enter the name of the person employed, name of employer, and the employee’s current gross
monthly amount received in wages, salaries or as tip income. Do not enter self-employment income in
this section. You may choose to provide an average of your income if a change in the future is clearly
indicated. Estimate a monthly amount by averaging income over a representative period of time as
described in WAC 182-509-0310.
Gross (before taxes are
Address of employer taken out) monthly
Name of person
Name of employer (including city, state and zip income (wages, salaries,
employed
code) tips, corporation,
S-corporation)

Self-employment income: Are you or anyone you are applying for currently self-employed?
No Yes
If yes, enter the current estimated net monthly income (profits once business expenses are paid) from
self- employment. Please see page ii for allowable business expenses. You may choose to provide an
average of your income if a change in the future is clearly indicated. Estimate a monthly amount by
averaging income over a representative period of time as described in WAC 182-509-0370.
Net monthly income
(do not enter
Name of person self-employed Name of company (if there is one) corporation or
S-corporation income
here)

Social Security income: Are you or anyone you are applying for receiving social security income?
No Yes
If yes, enter income received from Social Security Administration for retirement, disability, or survivor
benefits. Do not report supplemental social security (SSI) income.
Name of person receiving social security (not SSI) Gross monthly income

Rental income: Are you or anyone you are applying for receiving rental income? No Yes If
yes, enter monthly income received from renting out real estate or personal property. Enter net
income, after allowable business expenses.
Name of person receiving rental Name of property (if there is
Net monthly income
income one)

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Other income
Do not include child support or non-pension veteran’s payments. Check all that apply and tell us who
gets it, how much they receive, and how often they get it.
Alimony / spousal support Who $ How often
Who $ How often
Annuity or pension Who $ How often
Who $ How often
Capital gains Who $ How often
Who $ How often
Dividend, stocks or shares Who $ How often
Who $ How often
Farming income Who $ How often
Who $ How often
Foreign income Who $ How often
Who $ How often
Income from a trust Who $ How often
Who $ How often
Interest income Who $ How often
Who $ How often
IRA income Who $ How often
Who $ How often
Other taxable income Who $ How often
Who $ How often
Railroad retirement benefits Who $ How often
Who $ How often
Royalty income Who $ How often
Who $ How often
Taxable tribal income Who $ How often
Who $ How often
Unemployment benefits Who $ How often
Who $ How often
Will the members under age 19 or tax dependents on this application meet the threshold requirement to file a
federal tax return this year?
Name No Yes
Name No Yes
Name No Yes

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Deductions
These expenses can reduce the amount of your income that we count for some kinds of health care
coverage, just like the IRS uses them to reduce the amount of taxes you owe. If you choose not to
answer, you may still qualify for free or low cost health care coverage.
List below any deductions you claim on your tax return. Allowable deductions include:
Alimony/spousal support paid out Who $ How often
Who $ How often
Certain claimable business expenses Who $ How often
Who $ How often
Domestic production activities Who $ How often
Who $ How often
Educator expenses Who $ How often
Who $ How often
Health savings account contributions Who $ How often
Who $ How often
Moving costs for an official military Who $ How often
move
Who $ How often
Penalty on early withdrawal of Who $ How often
savings
Who $ How often
Pre-tax retirement account Who $ How often
contributions
Who $ How often
Self-employment health insurance Who $ How often
Who $ How often
Self-employment retirement plan Who $ How often
Who $ How often
Self-employment tax Who $ How often
Who $ How often
Student loan interest Who $ How often
Who $ How often

14
Supplemental information
Do any of the members applying for coverage need any of these services?
a. Long-term care services because you are currently living in or expect to move to a medical
institution, like nursing home. No Yes If yes, enter the name of the person:
Type of Facility:
b. An in-home care-giver? No Yes If yes, enter the name of the person:
c. Assisted Living care services? No Yes If yes, enter the name of the person:
d. Services through the Division of Developmental Disabilities? No Yes
If yes, enter the name of the person:
e. Hospice care? No Yes If yes, enter the name of the person:
f. Health care coverage because they are unable to work due to a health condition or disability?
No Yes If yes, enter the name of the person(s):
You will be required to complete HCA form 18-005
(www.hca.wa.gov/assets/free-or-low-cost/18-005.pdf) if any of the following apply:
• You are age 65 or older or on Medicare.
• You answered yes to any questions in a-f above.
• You are applying for the medically needy (MN) or the Healthcare for Workers with Disabilities
programs (HWD).
Read carefully before signing
Disclosure of information to other state and federal agencies:
I authorize Washington Healthplanfinder to electronically verify my tax return information during the
annual renewal process for up to 5 years. I understand that I am able to change my consent at any
time. By checking this box, I permit tax credits to be applied to my annual renewal without my taking
further action.
No Yes
I have read or had explained to me my rights and responsibilities and received a copy of Client Rights
and Responsibilities.
Declaration and signature
To apply for Washington Apple Health (Medicaid) free or low-cost coverage or tax credits to lower
your insurance premium, your signature is required below.
I have read and understood the information in this application. I declare, under penalty of perjury, the
information I have given in this application is true, correct, and complete to the best of my knowledge.

Signature Date

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