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You could be eligible for lower-cost or free coverage.\u003Cbr>• If you’re single , you may be able to use a short form .\u003Cbr>Visit [HealthCare.gov](HealthCare.gov).\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. |\n| --- | --- | --- |\n| | Apply faster online | Apply faster online [at](at HealthCare.gov)[ ](at HealthCare.gov)[HealthCare.gov](at HealthCare.gov) or [benefits.Ohio.gov](benefits.Ohio.gov). |\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 statem ents)\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. To view the Privacy Act Statement, visit: [https://medicaid.ohio.gov/wps/portal/gov/medicaid/](https://medicaid.ohio.gov/wps/portal/gov/medicaid/)[ ](https://medicaid.ohio.gov/wps/portal/gov/medicaid/)[families-and-individuals/coverage/already-covered/rights/notice-of-privacy-practices](families-and-individuals/coverage/already-covered/rights/notice-of-privacy-practices) |\n| | What happens next? | Send your complete , signed application to your local County Department of Job & Family Services office. Find your county office here: [jfs.ohio.gov/County/C ounty_Directory.pdf](jfs.ohio.gov/County/C ounty_Directory.pdf)\u003Cbr>If you don’t have all the inform ation we ask for, sign and submit your application anyway. We’ll follow-up with you within 1–2 weeks. You’ll get instructions on the next steps to complete your health coverage . If you don’t hear from us, call (800) 324-868 0 . Filling out this application doesn’t mean you have to buy health coverage. |\n| | Get help with this application | • Online: [HealthCare.gov](HealthCare.gov) or [benefits.Ohio.gov](benefits.Ohio.gov)\u003Cbr>• Phone: Call the Medicaid Consumer Hotline at (800) 324-8680.\u003Cbr>• In person : Contact your local County Department of Job & Family Services office.\u003Cbr>• En Español: Llame a nuestro centro de ayuda gratis al\u003Cbr>(800) 324-8680 . |\n\nNEED HELP WITH YOUR APPLICATION? Visit  [HealthCare.gov](HealthCare.gov) or [benefits.Ohio.gov](benefits.Ohio.gov) or call us at (800) 324-8680. Para obtener una copia de este formulario en Español, llame (800) 324-8680. If you need help in a language other than English, call (800) 324-8680 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users should call (800) 292-3572.  \nTHIS PAGE INTENTIONALLY LEFT BLANK.  \n STEP 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. Apartmen t or suite number |\n| --- | --- | --- | -","cbCaisoUKXJ27s8p","https://ap.wps.com/l/cbCaisoUKXJ27s8p","pdf",1105519,20,"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# STEP 1 Tell us about yourself\n## Contact person and identity fields\n## Address and phone information\n## Email and preferred language\n## Voter registration application (attached)\n## Programs to apply for\n# STEP 2 Tell us about your family\n## Who to include and who not to include","[{\"question\":\"What is this application used for?\",\"answer\":\"Use the application to see what you qualify for, including help paying for health coverage costs and access to Medicaid or CHIP options.\"},{\"question\":\"What information is needed to apply?\",\"answer\":\"You may need Social Security numbers, employer and income information, current health insurance policy numbers, and details about job-related health insurance.\"},{\"question\":\"What should happen after I submit the application?\",\"answer\":\"Send the complete, signed application to your local County Department of Job \\u0026 Family Services. If information is missing, sign and submit anyway, and follow-up is provided within 1–2 weeks with next-step instructions.\"}]","Medicaid Application Form - ODM 07216 - Application for Health Coverage & Help Paying Costs | PDF",1789835644,7]