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You could be eligible for lower-cost or free coverage.\u003Cbr>• Families that include immigrants can apply. You can apply for your child even if you aren’t eligible for coverage. Applying won’t affect your immigration status or chances of becoming a permanent resident or citizen.\u003Cbr>• If someone is helping you fill out this application, you may need to complete Appendix C.\u003Cbr>• If you are applying for someone other than a spouse or family member under age 21, an authorized representative form (Appendix C) must be completed.\u003Cbr>• If you are age 65 or older or disabled or any age and need assistance with nursing facility or community based care, you need to complete Appendix D. |\n| --- | --- | --- |\n| | Apply faster online | Apply faster online [at](at commonhelp.virginia.gov)[ ](at commonhelp.virginia.gov)[commonhelp.virginia.gov](at commonhelp.virginia.gov).\u003Cbr>For more information about Medicaid, FAMIS and Plan First visit\u003Cbr>[coverva.org](coverva.org). |\n| | What you may need to apply | • Social Security numbers (or document numbers for any legal immigrants who need insurance)\u003Cbr>• Employer and income information for everyone in your family (for example, from paystubs, W-2 forms, or wage and tax statements)\u003Cbr>• Policy numbers for any current health insurance\u003Cbr>• Information about any job-related health insurance available to your family |\n| | Why do we ask for this information? | We ask about income and other information to let you know what coverage you qualify for and if you can get any help paying for it. We’ll keep all the information you provide private and secure, as required by law. |\n| | What happens next? | If you use this paper application, send your complete, signed application to the local Department of Social Services in the city or county where you live. They will follow up with you to obtain additional information. Your application should be processed within 45 days from the date it was received. |\n| | Get help with this application | • Phone: Call Cover Virginia at 1-855-242-8282\u003Cbr>• In person: There will be application assisters in your area who can help. Visit our website at [coverva.org](coverva.org) or call 1-855-242-8282 for more information.\u003Cbr>• En Español: Llame a nuestro centro de ayuda gratis al 1-855-242-8282 |\n\nNEED HELP WITH YOUR APPLICATION? Visit the Cover Virginia website at [coverva.org](coverva.org) or call us at 1-855-242-8282. Para obtener una copia de este formulario en Español, llame 1-855-242-8282. If you need help in a language other than English, call 1-855-242-8282 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-888-221-1590.  \n02/01/21 Cover Page  \nSTEP 1  Tell us about yourself.  \n(We need one adult in the family to be the contact person for your application.)  \n1. First name Middle name Last name Suffix  \n\n| 2. Home address (Leave blank if you don’t have one.) |  |  |  |  |  |  |  |  | 3. Apartment or suite number |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| 4. City | 5. State |  |  |  |  | 6. ZIP code\u003Cbr>|  | 7. County |  |\n|  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |\n| 8. Mailing addres","cbCaiafA7KQZzhPr","https://ap.wps.com/l/cbCaiafA7KQZzhPr","pdf",330167,"English","# Things to know\n## Who can use this application?\n## Apply faster online\n## What you may need to apply\n## Why do we ask for this information?\n## What happens next?\n## Get help with this application\n# Cover page\n## STEP 1 Tell us about yourself\n## STEP 2 Tell us about your family","[{\"question\":\"What coverage options can this application help you qualify for?\",\"answer\":\"It helps you check eligibility for free or low-cost insurance through Medicaid, FAMIS, or Plan First. If you are not eligible for those, you may be referred to the Federal Health Insurance Marketplace for affordable private health insurance plans, which may include a tax credit to help pay premiums.\"},{\"question\":\"Who can use this application and who should be included?\",\"answer\":\"You can apply for anyone in your family, including yourself, a spouse, children under 21 who live with you, and certain parents or other dependents. The document also specifies people you do not have to include, such as some unmarried partners or relatives who file their own tax return.\"},{\"question\":\"What happens after you submit the paper application?\",\"answer\":\"Send your complete, signed application to your local Department of Social Services in the city or county where you live. Your application is processed within 45 days from the date it was received, and they follow up to obtain additional information.\"}]","Application for Health Coverage & Help Paying Costs - STEP 1 Tell us about yourself | PDF",1789835670,6]