Application forms for individuals - marketplace cms 2026

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The document is an application form for health coverage through the Health Insurance Marketplace. It outlines the process for individuals seeking health coverage without financial assistance, detailing how to complete and submit the application, what information is required, and how to receive help with the application process. It also provides information on eligibility for tax credits and low-cost programs like Medicaid and CHIP, as well as resources for assistance in multiple languages.

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Click ‘Get Form’ to open it in the editor.
Begin with Step 1: Tell us about yourself. Fill in your first name, middle name, last name, and suffix. Provide your home address, city, state, ZIP code, and county. If you have a different mailing address, include that as well.
Next, provide your daytime and evening phone numbers. Indicate if you wish to receive information via email and specify your preferred language.
Answer whether you need health coverage for yourself. If yes, complete the subsequent fields including Social Security Number (SSN), sex, date of birth, and citizenship status.
Proceed to Step 2: List anyone else who needs health coverage by filling out their details similarly as you did for yourself.
Continue through Steps 3 and 4 regarding American Indian/Alaska Native status and agreement & signature sections respectively.
Finally, review all entries for accuracy before mailing the completed application to the specified address.

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