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The form guides applicants through key steps: providing contact and household information, choosing preferred communication and language, and completing family details. 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If information is missing, sign and submit anyway; NJ FamilyCare follows up within 1–2 weeks and provides instructions for next steps.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},306122,1791333856,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":30,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":141},1236954509970,"https://us-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","Application for Health Coverage & Help Paying Costs  \nTHINGS TO KNOW  \nUse this application to see what coverage choices you qualify for  \n• Free or low-cost insurance from Medicaid or the Children’s Health Insurance Program (CHIP), known as NJ FamilyCare  \n•  \nyou stay well  \n• A new tax credit that can help pay your premiums for health coverage  \n| | Who can use this application? | • Use this application to apply for anyone in your family.\u003Cbr>• Apply even if you or your child already has health coverage. You could be eligible for lower-cost or free coverage.\u003Cbr>• If you’re single, you may be able to use a short form. [Visit](Visit njfamilycare.org)[ ](Visit njfamilycare.org)[njfamilycare.org](Visit njfamilycare.org).\u003Cbr>• Families that include immigrants can apply. You can apply for your\u003Cbr>\u003Cbr>immigration status or chances of becoming a permanent resident or citizen.\u003Cbr>• d to complete Appendix C. |\n| --- | --- | --- |\n| | Apply faster online | Apply faster online [at](at njfamilycare.org)[ ](at njfamilycare.org)[njfamilycare.org](at njfamilycare.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. To view the Privacy Act Statement, go to [njfamilycare.org](njfamilycare.org). |\n| | What happens next? | Send your complete, signed application to the address on page 7.\u003Cbr>If you don’t have all the information 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, visit [njfamilycare.org](njfamilycare.org) or call 1-800-701-0710. Filling out this application doesn’t mean you have to buy health coverage. |\n| | Get help with this application | • Online: [njfamilycare.org](njfamilycare.org)\u003Cbr>• Phone: Call our Help Center at 1-800-701-0710.\u003Cbr>• In person: There may be counselors in your area who can help. Visit our website or call 1-800-701-0710 for more information.\u003Cbr>• En Español: Llame a nuestro centro de ayuda gratis al\u003Cbr>1-800-701-0710. |\n\nNJ FamilyCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, sex, age or disability. If you speak any other language, language assistance services are available at no cost to you. Call 1-800-701-0710 (TTY: 1-800-701-0720) .  \nNJ FC-APP-E-0919  \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 | 7. County |  |\n| 8. Current mailing address (if different from home address) |  |  |  |  | 9. Apartment or suite number |\n| 10. City | 11. State |  | 12. ZIP code | 13. County |  |\n| 14. Phone number\u003Cbr>( ) – |  | 15. Other phone number\u003Cbr>( ) – |  |  |  |\n\n16. Do you want to get information about this application by email?  Yes  No  \nEmail address:    \n17. What is your preferred spoken or written language (if not English)?  \nSTEP 2  \nTell us about your family.  \nFamily Planning (Plan First Program)  \nIf any person on this application is not eligible for NJ FamilyCare, would you like them to be evaluated for family planning services (Plan First Program)?  \nYes  Check here for all applicants on this ap","cbCaiqII9LmuKClk","https://ap.wps.com/l/cbCaiqII9LmuKClk","pdf",3455378,"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# STEP 2 - Tell us about your family","[{\"question\":\"What coverage choices does the NJ FamilyCare application help you determine?\",\"answer\":\"It helps you see whether you qualify for free or low-cost insurance through Medicaid or CHIP (NJ FamilyCare) and for a tax credit that can help pay health coverage premiums.\"},{\"question\":\"What information is needed to complete the application?\",\"answer\":\"You may need Social Security numbers (or document numbers for legal immigrants), employer and income information, policy numbers for current insurance, and details about any job-related health insurance.\"},{\"question\":\"What happens after you submit a signed application?\",\"answer\":\"Send the completed, signed application to the address on page 7. If information is missing, sign and submit anyway; NJ FamilyCare follows up within 1–2 weeks and provides instructions for next steps.\"}]","NJ FamilyCare Application - Application for Health Coverage & Help Paying Costs | PDF",1789833032,6]