Health Coverage Templates

This Form is used for renewing medical benefits in the state of Oregon.

This document is used for providing information about COBRA continuation coverage and how to elect it.

This Form is used to collect information related to the Affordable Care Act and its provisions. The form helps individuals provide the necessary details for assessing their eligibility and enrolling in health insurance plans under the Affordable Care Act.

This Form is used for single adults in Arkansas to apply for health coverage.

This form is used for understanding your rights and responsibilities as a consumer of Medicaid health coverage in Ohio. It provides information about what you are entitled to as well as what is expected of you as a Medicaid recipient. This document helps you navigate your health coverage effectively.

This form is used for transmitting information from Medi-Cal to Healthy Families in California. It allows for the transfer of relevant documents and data between these two healthcare programs.

This Form is used for consenting to bridge from Medi-Cal to Healthy Families in California.

This Form is used for notifying the Office of Personnel Management (OPM) about any changes in your health benefits enrollment under the Federal Employees Health Benefits Program.

This Form is used for applying for health insurance coverage in California and obtaining an order for it.

This Form is used for coordinating insurance benefits for individuals in Delaware.

This form is used for enrolling in health benefits in the state of Delaware.

This document provides a summary of health benefits available to residents in California, including information about coverage, costs, and important plan details.

This Form is used for individuals in Missouri to create a specialized care plan for their personal needs.

This Form is used for reporting employment health coverage information in the state of Idaho. It is a required form for employers to provide information about the health coverage options they offer to their employees.

This Form is used for making a coverage election for Limited Scope Veba HRA in Montana.

This document is used to request a certificate of health coverage in Maryland. It provides proof of your health insurance and may be required for various purposes, such as enrollment in other health insurance plans or financial assistance programs.

This Form is used for selecting an authorized representative for health coverage in Indiana.

This form is used for providing a notice to Indiana residents about their rights and responsibilities regarding health coverage.

This Form is used to apply for health coverage in the state of Indiana.

Use this document, otherwise known as the IRS Health Coverage Form, for submitting a report to the Internal Revenue Service (IRS) and to taxpayers about individuals with minimum essential coverage who are not liable for the individual shared responsibility payment.

This form is used for applying for health coverage and financial assistance in Minnesota. It is specifically designed for the Somali-speaking community in the state.

This Form is used for applying for health coverage and financial assistance in Minnesota, specifically for the Hmong community.

This form is used for applying for health coverage and financial assistance to help cover the costs of healthcare in Minnesota. It is available in Vietnamese language for Vietnamese-speaking residents.

This Form is used for applying for health coverage and financial assistance in Minnesota, specifically for individuals who speak Russian.

This Form is used for enrolling in Special Needs Basiccare (SNBC) in Minnesota.

This document provides information about the participation costs for families in Missouri, especially those who speak Bengali. It includes details on how much families need to contribute and what services are covered.

This Form is used for giving consent to use Mo Healthnet/Medicaid in Missouri. It is available in Telugu language.

Use this form if you are an insurance provider and wish to inform the IRS about taxpayers who are eligible to receive minimum essential health coverage that meet the standards of the Affordable Care Act.

This is an IRS document released for those individuals who got payments during the calendar year of qualified health insurance payments for the benefit of eligible trade adjustment assistance.

This form is used for applying for health insurance in New York.

This form is used for applying to be a payor under New York State law. It allows individuals or organizations to request approval to make insurance payments on behalf of injured persons.

This Form is used for requesting prior approval for Medicare Health services in New Brunswick, Canada. It is available in both English and French.