Application for Health Coverage & Help Paying Costs ODM 07216 (7/2014)

• Affordable private health insurance plans that offer comprehensive

Use this application coverage to help you stay well
to see what you • A new tax credit that can immediately help pay your premiums for
qualify for health coverage
• Free or low-cost insurance from Medicaid or the Children’s Health
Insurance Program (CHIP)

• Use this application to apply for anyone in your family.

Who can use this
• Apply even if you or your child already has health coverage. You
application? could be eligible for lower-cost or free coverage.
• If you’re single, you may be able to use a short form.
Visit HealthCare.gov.
• 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.
• If someone is helping you fill out this application, you may need to
complete Appendix C.
THINGS TO KNOW

Apply faster
Apply faster online at HealthCare.gov or benefits.Ohio.gov.
online

What you may • Social Security Numbers (or document numbers for any legal
immigrants who need insurance)
need to apply
• Employer and income information for everyone in your family (for
example, from paystubs, W-2 forms, or wage and tax statements)
• Policy numbers for any current health insurance
• Information about any job-related health insurance available to your
family

Why do we ask for 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
this information? keep all the information you provide private and secure, as required
by law. To view the Privacy Act Statement, visit: http://medicaid.ohio.
gov/FOROHIOANS/AlreadyCovered/NoticeofPrivacyPractices.aspx

Send your complete, signed application to your local County

What happens Department of Job & Family Services office. Find your county office
next? here: jfs.ohio.gov/County/County_Directory.pdf
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, call (800) 324-8680. Filling out this
application doesn’t mean you have to buy health coverage.

Get help with this • Online: HealthCare.gov or benefits.Ohio.gov

• Phone: Call the Medicaid Consumer Hotline at (800) 324-8680.
application
• In person: Contact your local County Department of Job & Family
Services office.
• En Español: Llame a nuestro centro de ayuda gratis al
(800) 324-8680.
NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or 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.
THIS PAGE INTENTIONALLY LEFT BLANK.
 STEP 1 Tell us about yourself.
(We need one adult in the family to be the contact person for your application.)

1. First name, Middle name, Last name, & Suffix

2. Home address (Leave blank if you don’t have one.) 3. Apartment or suite
number

4. City 5. State 6. ZIP code 7. County

8. Mailing address (if different from home address) 9. Apartment or suite

number

10. City 11. State 12. ZIP code 13. County

14. Phone number 15. Other phone number

( ) - ( ) -

16. Do you want to get information about this application by email? Yes No

Email address:

17. What is your preferred spoken or written language (if not English)?

18. VOTER REGISTRATION APPLICATION ATTACHED - ASSISTANCE AVAILABLE

If you are not registered to vote where you live now, would you like to apply to register to vote today?
YES, I want to register. NO, I do not want to register to vote.
If you do not check either box, you will be considered to have decided not to register to vote at this time.

19. For which programs would you like to apply? (Please check). For information about these programs, please see Appendix D.

Healthy Start & Healthy Families (Medicaid) Nutritional Program for Women, Infants & Children (WIC)
Child & Family Health Services (CFHS) Bureau for Children with Medical Handicaps (BCMH)
Help Me Grow

STEP 2 Tell us about your family.

Who do you need to include on this application? Tell us about them.
If you file taxes, we need to know about everyone on your tax return. (You don’t need to file taxes to get health
coverage).

DO Include: You DON’T have to include:

• Yourself • Your unmarried partner who doesn’t need health
• Your spouse coverage, unless you have a common child who lives
• Your children under 21 who live with you with you.
• Your unmarried partner who needs health coverage • Your unmarried partner’s children
• Anyone you include on your tax return, even if they • Your parents who live with you, but file their own tax
don’t live with you return (if you’re over 21)
• Anyone else under 21 who you take care of and lives • Other adult relatives who file their own tax return
with you
• Anyone else who lives with you but is temporarily
absent and there is a definite plan for their return.

The amount of assistance or type of program you qualify for depends on the number of people in your family and
their incomes. This information helps us make sure everyone gets the best coverage they can.
Complete Step 2 for each person in your family. Start with yourself, then add other adults and children. If you have
more than 2 people in your family, you’ll need to make a copy of the pages and attach them. You don’t need to
provide immigration status or a Social Security Number (SSN) for family members who don’t need health coverage.
We’ll keep all the information you provide private and secure as required by law. We’ll use personal information only
to check if you’re eligible for health coverage.

ODM 07216 (7/2014) Page 1 of 7

Formerly JFS 07216
 STEP 2: PERSON 1 (Start with yourself)
Complete Step 2 for yourself, your spouse/partner and children who live with you and/or anyone on your same federal income
tax return if you file one. See page 1 for more information about who to include. If you don’t file a tax return, remember to still add
family members who live with you.
1. First name, Middle name, Last name, & Suffix 2. Relationship to you?
SELF
3. Date of birth (mm/dd/yyyy) 4. Sex Male Female

5. Social Security number (SSN) - -

We need this if you want health coverage and have an SSN. Providing your SSN can be helpful if you don’t want health coverage
too since it can speed up the application process. We use SSNs to check income and other information to see who’s eligible for
help with health coverage costs. If someone wants help getting an SSN, call 1-800-772-1213 or visit socialsecurity.gov..TTY users
should call 1-800-325-0778.

6. Do you plan to file a federal income tax return NEXT YEAR?

(You can still apply for health insurance even if you don’t file a federal income tax return.)
YES. If yes, please answer questions a–c. NO. If no, skip to question c.

a. Will you file jointly with a spouse? Yes No

If yes, name of spouse:
b. Will you claim any dependents on your tax return? Yes No
If yes, list name(s) of dependents:
c. Will you be claimed as a dependent on someone’s tax return? Yes No
If yes, please list the name of the tax filer:
How are you related to the tax filer?

7. Are you pregnant? Yes No a. If yes, how many babies are expected during this pregnancy?
What is your expected due date?

8. Do you want health coverage? Even if you have insurance, there might be a program with better coverage or lower costs.

YES. If yes, answer all the questions below. NO. If no, SKIP to the income questions on page 3.
Leave the rest of this page blank.

9. Do you have any physical, mental, or emotional health condition(s) that causes limitations in activities (like bathing, dressing,
daily chores, etc) or live in a medical facility or nursing home? Yes No

10. Are you a U.S. citizen or U.S. national? Yes No

11. If you aren’t a U.S. citizen or U.S. national, but you have immigration documents, please provide the following:
a. Alien number
b. Document type c. Document ID number
d. Have you lived in the U.S. since August 22, 1996? Yes No
e. Are you, your spouse, or your parent a veteran or an active duty member of the U.S. military? Yes No

12. Do you want help paying for medical bills from the last 3 months? Yes No

13. If you live with at least one child under the age of 19, are you the main person taking care of this child? Yes No

14. Are you a full-time student? Yes No 15. Were you in foster care at age 18 or older? Yes No

16. If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.)

Mexican Mexican American Chicano/a Puerto Rican Cuban Other
17. Race (OPTIONAL—check all that apply.)
White American Indian or Filipino Vietnamese Guamanian or Chamorro
Black or African Alaska Native Japanese Other Asian Samoan
American Asian Indian Korean Native Hawaiian Other Pacific Islander
Chinese Other

ODM 07216 (7/2014) Page 2 of 7

Formerly JFS 07216
 STEP 2: PERSON 1 (Continue with yourself)
Current Job & Income Information
Employed Self-employed Not employed
If you’re currently employed, tell Skip to question 27. Skip to question 28.
us about your income. Start with
question 18..

CURRENT JOB 1:
18. Employer name and address 19. Employer phone number
( ) -

20. Wages/tips (before taxes) Hourly Weekly Every 2 weeks Twice a month Monthly Yearly
$
21. Average hours worked each WEEK

CURRENT JOB 2: (If you have more jobs and need more space, attach another sheet of paper.)
22. Employer name and address 23. Employer phone number
( ) -

24. Wages/tips (before taxes) Hourly Weekly Every 2 weeks Twice a month Monthly Yearly
$
25. Average hours worked each WEEK

26. In the past year, did you: Change jobs Stop working Start working fewer hours None of these

27. If self-employed, answer the following questions:

a. Type of work b. How much net income (profits, once business expenses are
paid) from this self-employment will you get this month?

28. OTHER INCOME THIS MONTH: Check all that apply. Tell us the amount and how often you receive it.
NOTE: You don’t need to tell us about child support, veteran’s payment, or Supplemental Security Income (SSI).

None
Unemployment $ How often? Net farming/fishing $ How often?

Pensions $ How often? Net rental/royalty $ How often?

Social Security $ How often? Other income $ How often?

Retirement accounts $ How often? Type:

Alimony received $ How often?

29. DEDUCTIONS: Check all that apply. Tell us the amount and how often you receive it.
If you pay for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health
coverage a little lower.

Alimony paid $ How often? Other deductions $ How often?

Student loan interest $ How often? Type:

30. YEARLY INCOME: Complete only if your income changes from month to month.
If you don’t expect changes to your monthly income, skip to the next person.

Your total income this year Your total income next year (if you think it will be different)
$ $

THANKS! Please complete STEP 2: Person 2 for anyone else listed in the “Do Include” column on Page 1.

ODM 07216 (7/2014) Page 3 of 7

Formerly JFS 07216
 If you have more than two people to include, use copies of Appendix E to provide
STEP 2: PERSON 2 information about additional people for this application.

Complete Step 2 for yourself, your spouse/partner, and children who live with you and/or anyone on your same federal income
tax return if you file one. See page 1 for more information about who to include. If you don’t file a tax return, remember to still add
family members who live with you.
1. First name, Middle name, Last name, & Suffix 2. Relationship to you

3. Date of birth (mm/dd/yyyy) 4. Sex Male Female

5. Social Security number (SSN) - -

We need this if you want health coverage and have an SSN.
6. Does PERSON 2 live at the same address as you? Yes No
If no, list address:
7. Does PERSON 2 plan to file a federal income tax return NEXT YEAR?
(You can still apply for health insurance even if you don’t file a federal income tax return.)
YES. If yes, please answer questions a–c. NO. If no, skip to question c.
a. Will PERSON 2 file jointly with a spouse? Yes No
If yes, name of spouse:
b. Will PERSON 2 claim any dependents on his or her tax return? Yes No
If yes, list name(s) of dependents:
c. Will PERSON 2 be claimed as a dependent on someone’s tax return? Yes No
If yes, please list the name of the tax filer:
How is PERSON 2 related to the tax filer?

8. Is PERSON 2 pregnant? Yes No a. If yes, how many babies are expected during this pregnancy?
What is your expected due date?
9. Does PERSON 2 want health coverage? Even if they have insurance, there might be a program with better coverage or lower
costs.
YES. If yes, answer all the questions below. NO. If no, SKIP to the income questions on page 5.
Leave the rest of this page blank.

10. Does PERSON 2 have any physical, mental, or emotional health condition(s) that causes limitations in activities (like bathing,
dressing, daily chores, etc) or live in a medical facility or nursing home? Yes No

11. Is PERSON 2 a U.S. citizen or U.S. national? Yes No

12. If PERSON 2 isn’t a U.S. citizen or U.S. national, but has immigration documents, please provide the following:
a. Alien number
b. Document type c. Document ID number
d. Has PERSON 2 lived in the U.S. since August 22, 1996? Yes No
e. Is PERSON 2, their spouse, or their parent a veteran or an active duty member of the U.S. military? Yes No
13. Does PERSON 2 want help paying for 14. If PERSON 2 lives with at least one child 15. Was PERSON 2 in foster care at
medical bills from the last 3 months? under the age of 19, are they the main person age 18 or older?
Yes No taking care of this child? Yes No
Yes No

Please answer the following questions if PERSON 2 is 22 or younger:

16. Did PERSON 2 have insurance through a job and lose it within the past 3 months? Yes No
a. If yes, end date: b. Reason the insurance ended:

17. Is PERSON 2 a full-time student? Yes No

18. If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.)

Mexican Mexican American Chicano/a Puerto Rican Cuban Other

19. Race (OPTIONAL—check all that apply.)

White American Indian or Filipino Vietnamese Guamanian or Chamorro
Black or African Alaska Native Japanese Other Asian Samoan
American Asian Indian Korean Native Hawaiian Other Pacific Islander
Chinese Other

Now, tell us about any income from PERSON 2 on the back.

ODM 07216 (7/2014) Page 4 of 7
Formerly JFS 07216
 STEP 2: PERSON 2
Current Job & Income Information
Employed Self-employed Not employed
If you’re currently employed, tell Skip to question 29. Skip to question 30.
us about your income. Start with
question 20..

CURRENT JOB 1:
20. Employer name and address 21. Employer phone number
( ) -

22. Wages/tips (before taxes) Hourly Weekly Every 2 weeks Twice a month Monthly Yearly
$
23. Average hours worked each WEEK

CURRENT JOB 2: (If you have more jobs and need more space, attach another sheet of paper.)
24. Employer name and address 25. Employer phone number
( ) -

26. Wages/tips (before taxes) Hourly Weekly Every 2 weeks Twice a month Monthly Yearly
$
27. Average hours worked each WEEK

28. In the past year, did PERSON 2: Change jobs Stop working Start working fewer hours None of these

29. If self-employed, answer the following questions:

a. Type of work b. How much net income (profits once business expenses
are paid) will you get from this self-employment this
month?

30. OTHER INCOME THIS MONTH: Check all that apply. Tell us the amount and how often you receive it.
NOTE: You don’t need to tell us about child support, veteran’s payment, or Supplemental Security Income (SSI).

None
Unemployment $ How often? Net farming/fishing $ How often?

Pensions $ How often? Net rental/royalty $ How often?

Social Security $ How often? Other income $ How often?

Retirement accounts $ How often? Type:

Alimony received $ How often?

31. DEDUCTIONS: Check all that apply. Tell us the amount and how often PERSON 2 receives it.
If PERSON 2 pays for certain things that can be deducted on a federal income tax return, telling us about them could make the cost
of health coverage a little lower.

Alimony paid $ How often? Other deductions $ How often?

Student loan interest $ How often? Type:

32. YEARLY INCOME: Complete only if PERSON 2’s income changes from month to month.
If you don’t expect changes to PERSON 2’s monthly income, add another person or skip to the next section.
PERSON 2’s total income this year PERSON 2’s total income next year (if you think it will be differ-
ent)
$
$

THANKS! This is all we need to know about PERSON 2.

ODM 07216 (7/2014) Page 5 of 7
Formerly JFS 07216
 STEP 3 American Indian or Alaska Native family member(s)

1. Are you or is anyone in your family American Indian or Alaska Native?

If No, skip to Step 4.
Yes. If yes, please also complete Appendix B.

STEP 4 Your Family’s Health Coverage

Answer these questions for anyone who needs health coverage.

1. Is anyone enrolled in health coverage now from the following?
YES. If yes, check the type of coverage and write the person(s)’ name(s) next to the coverage they have. NO.

Medicaid Employer insurance:

CHIP Name of health insurance:
Policy number:
Medicare
Is this COBRA coverage? Yes No
TRICARE (Don’t check if you have direct care or Line of Duty) Is this a retiree health plan? Yes No
Other
Name of health insurance:
VA health care programs
Policy number:
Peace Corps
Is this a limited-benefit plan (like a school accident policy)?
Yes No

2. Is anyone listed on this application offered health coverage from a job? Check yes even if the coverage is from someone else’s
job, such as a parent or spouse (including a parent or spouse not included on this application).
YES. If yes, you’ll need to complete and include Appendix A.
NO. If no, continue to Step 5.

STEP 5 Read & sign this application.

• I’m signing this application under penalty of perjury which means I’ve provided true answers to all the questions on
this form to the best of my knowledge. I know that I may be subject to penalties under federal law if I provide false
and or untrue information.  
• I know that I must tell the Ohio Department of Medicaid if anything changes (and is different than) what I wrote on
this application. I can call 1-800-324-8680 to report any changes within 10 days. I understand that a change in my
information could affect the eligibility for member(s) of my household.
• I know that under federal law, discrimination isn’t permitted on the basis of race, color, national origin, sex, age, sexual
orientation, gender identity, or disability. I can file a complaint of discrimination by visiting www.hhs.gov/ocr/office/file

Check one of the following:

I con.rm that no one applying for health insurance on this application is incarcerated (detained or jailed).

is incarcerated (detained or jailed).

(name of person)

We need this information to check your eligibility for help paying for health coverage if you choose to apply. We’ll check
your answers using information in our electronic databases and databases from the Internal Revenue Service (IRS), Social
Security, the Department of Homeland Security, and/or a consumer reporting agency. If the information doesn’t match,
we may ask you to send us proof.

ODM 07216 (7/2014) Page 6 of 7

Formerly JFS 07216
 STEP 5 Read & sign this application: continued

Renewal of coverage in future years

To make it easier to determine my eligibility for help paying for health coverage in future years, I agree to allow the
Ohio Department of Medicaid or Marketplace to use income data, including information from tax returns.
The Ohio Department of Medicaid or the Marketplace will send me a notice, let me make any changes, and I can opt
out at any time.
Yes, renew my/our eligibility automatically for the next
5 years (the maximum number of years allowed), or for a shorter number of years:
4 years 3 years 2 years 1 year Don’t use information from tax returns to renew my coverage.

If anyone on this application is eligible for Medicaid

• I am giving to the Medicaid agency our rights to pursue and get any money from other health insurance, legal
settlements, or other third parties. I am also giving to the Medicaid agency rights to pursue and get medical support
from a spouse or parent.
• Does any child on this application have a parent living outside of the home? Yes No
• If yes, I know I will be asked to cooperate with the agency that collects medical support from an absent parent. If
I think that cooperating to collect medical support will harm me or my children, I can tell Medicaid and I may not
have to cooperate.
• I authorize any person who furnishes health care or medical supplies to give the Ohio Department of Medicaid,
the Ohio Department of Job & Family Services, or the Ohio Department of Health any information related to the
extent, duration, and scope of services provided under the Healthy Start, Healthy Families Medicaid program, WIC,
and medical assistance programs. I also authorize the Ohio Department of Medicaid, the Ohio Department of Job
& Family Services, and the Ohio Department of Health to exchange any information I have provided on this form, to
enable the departments to determine my eligibility.

My right to appeal
If I think the Ohio Department of Medicaid or the Health Insurance Marketplace has made a mistake, I can appeal its
decision. To appeal means to tell someone at the Ohio Department of Medicaid or the Health Insurance Marketplace
that I think the action is wrong, and ask for a fair review of the action. I know that I can find out how to appeal by
contacting the Ohio Department of Medicaid at 1-800-324-8680. I know that I can be represented in the process by
someone other than myself. My eligibility and other important information will be explained to me.

Sign this application. The person who filled out Step 1 should sign this application. If you’re an authorized
representative you may sign here, as long as you have provided the information required in Appendix C.

Signature Date (mm/dd/yyyy)

STEP 6 Mail completed application.

Mail your complete, signed application to your local County Department of Job & Family Services office.

Find your local office by visiting this link: jfs.ohio.gov/County/County_Directory.pdf

You can complete the voter registration form attached to this application.

ODM 07216 (7/2014) Page 7 of 7

Formerly JFS 07216
THIS PAGE INTENTIONALLY LEFT BLANK.
 Ohio Department of Medicaid
APPENDIX A ODM 07216 - A (7/2014)

Health Coverage from Jobs

You DO NOT need to answer these questions unless someone in the household is eligible for health coverage from a
job. Attach a copy of this page for each job that offers coverage.

Tell us about the job that offers coverage.

Take the Employer Coverage Tool on the next page to the employer who offers coverage to help you answer
these questions. You only need to include this page when you send in your application, not the Employer Coverage
Tool.

EMPLOYEE Information
1. Employee name (First, Middle, Last, Suffix) 2. Employee Social Security number
- -

EMPLOYER Information
3. Employer name 4. Employer Identification Number (EIN)
-
5. Employer address 6. Employer phone number
( ) -
7. City 8. State 9. ZIP code

10. Who can we contact about employee health coverage at this job?

11. Phone number (if different from above) 12. Email address
( ) -

13. Are you currently eligible for coverage offered by this employer, or will you become eligible in the next 3 months?
Yes (Continue)
13a. If you’re in a waiting or probationary period, when can you enroll in coverage?
(mm/dd/yyyy)
List the names of anyone else who is eligible for coverage from this job.

Name: Name: Name:

No (Stop here and go to Step 5 in the application)

Tell us about the health plan offered by this employer.

14. Does the employer offer a health plan that meets the minimum value standard*? Yes No

15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don’t include family plans):
If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum
discount for any tobacco cessation programs, and did not receive any other discounts based on wellness programs.
a. How much would the employee have to pay in premiums for this plan? $
b. How often? Weekly Every 2 weeks Twice a month Once a month Quarterly Yearly

16. What change will the employer make for the new plan year (if known)?
Employer won’t offer health coverage
 Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to
the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See
question 15.)
a. How much will the employee have to pay in premiums for that plan? $
b. How often? Weekly Every 2 weeks Twice a month Once a month Quarterly Yearly
Date of change (mm/dd/yyyy):

* An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of the total allowed benefit costs covered by the
plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986).

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.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.
Appendix A - Page 1 of 2
 EMPLOYER COVERAGE TOOL
Use this tool to help answer questions in Appendix A about any employer health coverage that you’re eligible for (even
if it’s from another person’s job, like a parent or spouse). The information in the numbered boxes below match the
boxes on Appendix A. For example, the answer to question 14 on this page should match question 14 on Appendix A.
Write your name and Social Security number in boxes 1 and 2 and ask the employer to fill out the rest of the form.
Complete one tool for each employer that offers health coverage.

EMPLOYEE Information
The employee needs to fill out this section.
1. Employee name (First, Middle, Last, Suffix) 2. Social Security Number
- -

EMPLOYER Information
Ask the employer for this information.
3. Employer name 4. Employer Identification Number (EIN)
-
5. Employer address (the Marketplace will send notices to this address) 6. Employer phone number
( ) –
7. City 8. State 9. ZIP code

10. Who can we contact about employee health coverage at this job?

11. Phone number (if different from above) 12. Email address
( ) –

13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in the next 3 months?
Yes (Continue)
13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee
eligible for coverage? (mm/dd/yyyy) (Continue)
No (STOP and return this form to employee)

Tell us about the health plan offered by this employer.

Does the employer offer a health plan that covers an employee’s spouse or dependent?
Yes. Which people? Spouse Dependent(s)
No
(Go to question 14)
14. Does the employer offer a health plan that meets the minimum value standard*?
Yes (Go to question 15) No (STOP and return form to employee)
15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don’t include family plans):
If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum
discount for any tobacco cessation programs, and didn’t receive any other discounts based on wellness programs.
a. How much would the employee have to pay in premiums for this plan? $
b. How often? Weekly Every 2 weeks Twice a month Once a month Quarterly Yearly
If the plan year will end soon and you know that the health plans offered will change, go to question 16. If you don’t know, STOP
and return form to employee.
16. What change will the employer make for the new plan year?
Employer won’t offer health coverage
Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to
the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See
question 15.)
a. How much will the employee have to pay in premiums for that plan? $
b. How often? Weekly Every 2 weeks Twice a month Once a month Quarterly Yearly
Date of change (mm/dd/yyyy):
* An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of the total allowed benefit costs covered by the plan is no
less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986).

ODM 07216 - A (7/2014)

Appendix A - Page 2 of 2
APPENDIX B
Ohio Department of Medicaid
ODM 07216 - B (7/2014)

American Indian or Alaska Native Family Member (AI/AN)

Complete this appendix if you or a family member are American Indian or Alaska Native. Submit this with your
Application for Health Coverage & Help Paying Costs.

Tell us about your American Indian or Alaska Native family member(s).

American Indians and Alaska Natives can get services from the Indian Health Services, tribal health programs, or urban
Indian health programs. They also may not have to pay cost sharing and may get special monthly enrollment periods.
Answer the following questions to make sure your family gets the most help possible.

NOTE: If you have more people to include, make a copy of this page and attach.

AI/AN PERSON 1 AI/AN PERSON 2

1. Name First Middle First Middle
(First name, Middle name, Last name)
Last Last

2. Member of a federally recognized tribe? Yes Yes

If yes, tribe name If yes, tribe name

No No

3. Has this person ever gotten a service from Yes Yes

the Indian Health Service, a tribal health
program, or urban Indian health program, No No
or through a referral from one of these If no, is this person eligible to get If no, is this person eligible to get
programs? services from the Indian Health services from the Indian Health
Service, tribal health programs, or Service, tribal health programs, or
urban Indian health programs, or urban Indian health programs, or
through a referral from one of these through a referral from one of these
programs? programs?

Yes No Yes No

4. Certain money received may not be

$ $
counted for Medicaid or the Children’s
Health Insurance Program (CHIP). List any How often? How often?
income (amount and how often) reported
on your application that includes money
from these sources:
• Per capita payments from a tribe that
come from natural resources, usage
rights, leases, or royalties
• Payments from natural resources,
farming, ranching, fishing, leases, or
royalties from land designated as Indian
trust land by the Department of Interior
(including reservations and former
reservations)
• Money from selling things that have
cultural significance

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or 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.

Appendix B
APPENDIX C
Ohio Department of Medicaid
ODM07216 - C (7/2014)

Assistance with Completing this Application

You can choose an authorized representative.
You can give a trusted person permission to talk about this application with us, see your information, and act for
you on matters related to this application, including getting information about your application and signing your
application on your behalf. This person is called an “authorized representative.” If you ever need to change your
authorized representative, contact your local County Department of Job and Family Services. If you’re a legally
appointed representative for someone on this application, submit proof with the application.

1. Name of authorized representative (First name, Middle name, Last name, Suffix)

2. Address 3. Apartment or suite number

4. City 5. State 6. ZIP code

7. Phone number
( ) –
8. Organization name 9. ID number (if applicable)

By signing, you allow this person to sign your application, get official information about this application, and act for
you on all future matters with this agency.
10. Your signature 11. Date (mm/dd/yyyy)

For certified application counselors, navigators, agents, and brokers only.

Complete this section if you’re a certified application counselor, navigator, agent, or broker filling out this application
for somebody else.
1. Application start date (mm/dd/yyyy)

2. First name, Middle name, Last name, & Suffix

3. Organization name 4. ID number (if applicable)

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or 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.
Appendix C
APPENDIX D
Ohio Department of Medicaid
ODM 07216 - D (7/2014)

HEALTH COVERAGE PROGRAMS

Ohio offers families a variety of options for getting health care services. Below is a brief description of
four publicly funded programs that are available throughout Ohio. Families can apply for one or all of the
following programs by using the attached application.

Healthy Start and Healthy Families

The Healthy Start and Healthy Families programs offer free or low-cost health coverage to families, children (up to
age 19) and pregnant women. Certain young adults meeting specific criteria may be covered up to age 21.

Coverage includes: doctor visits, hospital care, pregnancy-related services, prescriptions, vision, dental, substance
abuse treatment, mental health services and much more! These are important health care services that your family
needs to stay healthy and strong. Healthy Start and Healthy Families are Medicaid programs administered by the
Ohio Department of Medicaid. For more information, please call 1-800-324-8680 or visit medicaid.ohio.gov.

Women, Infants & Children (WIC)

The Women, Infants, and Children (WIC) program provides nutritious foods, important nutrition information, and
breastfeeding education and support. It also helps eligible families find health care or other services they need. To
be eligible for WIC, you must be a woman who is pregnant or breastfeeding or have a baby less than six months old.
Children from birth to age 5 also qualify. Families must meet WIC income and medical or nutritional risk guidelines.
To apply, complete the attached application or visit your local WIC clinic. The WIC program is administered by the
Ohio Department of Health.

Child & Family Health Services (CFHS)

The Child and Family Health Services (CFHS) program in your area may provide one or more of the following
services: child and adolescent health care and prenatal care. Clinics offer physicals, nutrition counseling, social
services, laboratory tests, health education and more. The cost of the clinic services is based on your family size
and income but no one is turned away from services if they cannot pay. To apply, please complete the attached
application or visit your local CFHS. This program is administered by the Ohio Department of Health.

Children with Medical Handicaps (BCMH)

The Children with Medical Handicaps program (BCMH) is a health care program providing services for children with
special health care needs. To receive BCMH services, a child must be an Ohio resident younger than age 21 and be
under the care of a BCMH-approved doctor. Families must also meet income eligibility criteria. BCMH works closely
with public health nurses in local health departments to identify and coordinate services for children with medically
handicapping conditions and their families. For more information, families can contact their local health department
or call (800) 755 - GROW (4769). This program is administered by the Ohio Department of Health.

Help Me Grow (HMG)

The Help Me Grow Home Visiting program provides parenting education for pregnant women and first time
mothers. The program helps families with young children connect with resources so that children start school
healthy and ready to learn. The Help Me Grow Early Intervention program provides services to families with children
birth to age three with developmental disabilities. Services are coordinated and families are connected to services
which build the parent’s ability to enhance their child’s development so that children with disabilities or delays in
development start school healthy and ready to learn.

Those who are interested in getting cash assistance through Ohio Works First or getting
Food Assistance should contact their local County Department of Job & Family Services.

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or 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.
Appendix D
APPENDIX E Ohio Department of Medicaid
ODM 07216 - E (7/2014)

STEP 2 ADDITIONAL PERSON (give this person a number)

Complete Step 2 for yourself, your spouse/partner, and children who live with you and/or anyone on your same federal income
tax return if you file one. See page 1 for more information about who to include. If you don’t file a tax return, remember to still add
family members who live with you.
1. First name, Middle name, Last name, & Suffix 2. Relationship to you

3. Date of birth (mm/dd/yyyy) 4. Sex Male Female

5. Social Security number (SSN) - -

We need this if you want health coverage and have an SSN.
6. Does this person live at the same address as you? Yes No
If no, list address:
7. Does this person plan to file a federal income tax return NEXT YEAR?
(You can still apply for health insurance even if you don’t file a federal income tax return.)
YES. If yes, please answer questions a–c. NO. If no, skip to question c.
a. Will this person file jointly with a spouse? Yes No
If yes, name of spouse:
b. Will this person claim any dependents on his or her tax return? Yes No
If yes, list name(s) of dependents:
c. Will this person be claimed as a dependent on someone’s tax return? Yes No
If yes, please list the name of the tax filer:
How is this person related to the tax filer?

8. Is this person pregnant? Yes No a. If yes, how many babies are expected during this pregnancy?
What is the expected due date?
9. Does this person want health coverage? Even if they have insurance, there might be a program with better coverage or lower
costs.
YES. If yes, answer all the questions below. NO. If no, SKIP to the income questions on page 5.
Leave the rest of this page blank.

10. Does this person have any physical, mental, or emotional health condition(s) that causes limitations in activities (like bathing,
dressing, daily chores, etc) or live in a medical facility or nursing home? Yes No

11. Is this person a U.S. citizen or U.S. national? Yes No

12. If this person isn’t a U.S. citizen or U.S. national, but has immigration documents, please provide the following:
a. Alien number
b. Document type c. Document ID number
d. Has this person lived in the U.S. since August 22, 1996? Yes No
e. Is this person, their spouse, or their parent a veteran or an active duty member of the U.S. military? Yes No
13. Does this person want help paying for 14. If this person lives with at least one child 15. Was this person in foster care at
medical bills from the last 3 months? under the age of 19, are they the main person age 18 or older?
Yes No taking care of this child? Yes No
Yes No

Please answer the following questions if this person is 22 or younger:

16. Did this person have insurance through a job and lose it within the past 3 months? Yes No
a. If yes, end date: b. Reason the insurance ended:

17. Is PERSON 2 a full-time student? Yes No

18. If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.)

Mexican Mexican American Chicano/a Puerto Rican Cuban Other

19. Race (OPTIONAL—check all that apply.)

White American Indian or Filipino Vietnamese Guamanian or Chamorro
Black or African Alaska Native Japanese Other Asian Samoan
American Asian Indian Korean Native Hawaiian Other Pacific Islander
Chinese Other

Now, tell us about any income from ADDITIONAL PERSON on the back.
NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or 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.
 STEP 2 ADDITIONAL PERSON
Current Job & Income Information
Employed Self-employed Not employed
If this person is currently employed, Skip to question 29. Skip to question 30.
tell us about their income. Start with
question 20..

CURRENT JOB 1:
20. Employer name and address 21. Employer phone number
( ) -

22. Wages/tips (before taxes) Hourly Weekly Every 2 weeks Twice a month Monthly Yearly
$
23. Average hours worked each WEEK

CURRENT JOB 2: (If this person has more jobs and need more space, attach another sheet of paper.)
24. Employer name and address 25. Employer phone number
( ) -

26. Wages/tips (before taxes) Hourly Weekly Every 2 weeks Twice a month Monthly Yearly
$
27. Average hours worked each WEEK

28. In the past year, did this person: Change jobs Stop working Start working fewer hours None of these

29. If self-employed, answer the following questions:

a. Type of work b. How much net income (profits once business expenses
are paid) will this person get from this self-employment
this month?

30. OTHER INCOME THIS MONTH: Check all that apply. Tell us the amount and how often this person receives it.
NOTE: You don’t need to tell us about child support, veteran’s payment, or Supplemental Security Income (SSI).

None
Unemployment $ How often? Net farming/fishing $ How often?

Pensions $ How often? Net rental/royalty $ How often?

Social Security $ How often? Other income $ How often?

Retirement accounts $ How often? Type:

Alimony received $ How often?

31. DEDUCTIONS: Check all that apply. Tell us the amount and how often this person receives it.
If this person pays for certain things that can be deducted on a federal income tax return, telling us about them could make the cost
of health coverage a little lower.

Alimony paid $ How often? Other deductions $ How often?

Student loan interest $ How often? Type:

32. YEARLY INCOME: Complete only if this person’s income changes from month to month.
If you don’t expect changes to this person’s monthly income, add another person or skip to the next section.
This person’s total income this year: This person’s total income next year (if you think it will be differ-
ent):
$
$

THANKS! This is all we need to know about this ADDITIONAL PERSON.

ODM 07216 - E (7/2014) Appendix E Page 2 of 2

Formerly JFS 07216
THIS PAGE INTENTIONALLY LEFT BLANK.
Reset Form
Voter Registration and Information Update Form
Please read instructions carefully. Please type or print clearly with blue or black ink.
For further information, you may consult the Secretary of State’s website at: www.OhioSecretaryofState.gov or call 1-877-767-6446.

Eligibility Registering by Mail

You are qualified to register to vote in Ohio if you meet all the If you register by mail and do not provide either an Ohio driver’s license
number or the last four digits of your Social Security number, you must
following requirements:
enclose with your application a copy of one of the following forms of
1. You are a citizen of the United States. identification:
2. You will be at least 18 years old on or before the day of
the general election. Current and valid photo identification, a military identification, or
3. You will be a resident of Ohio for at least 30 days a current (within the last 12 months) utility bill, bank statement,
paycheck, government check or government document (other
immediately before the election in which you want to vote.
than a notice of voter registration mailed by a board of
4. You are not incarcerated (in jail or in prison) for a felony elections) that shows your name and current address.
conviction.
5. You have not been declared incompetent for voting Residency Requirements
purposes by a probate court. Your voting residence is the location that you consider to be a
6. You have not been permanently disenfranchised for permanent, not a temporary, residence. Your voting residence is the
place in which your habitation is fixed and to which, whenever you
violations of election laws. are absent, you intend to return. If you do not have a fixed place of
habitation, but you are a consistent or regular inhabitant of a shelter or
Use this form to register to vote or to update your current Ohio other location to which you intend to return, you may use that shelter
registration if you have changed your address or name. or other location as your residence for purposes of registering to vote.
If you have questions about your specific residency circumstances, you
NOTICE: This form must be received or postmarked by the 30th day may contact your local board of elections for further information.
before an election at which you intend to vote. You will be notified by
your county board of elections of the location where you vote. If you Your Signature
do not receive a notice following timely submission of this form, please In the area below the arrow in Box 14, please write your cursive,
contact your county board of elections. hand-written signature or make your legal mark, taking care that it
does not touch the surrounding lines so when it is digitally imaged by
Numbers 1 and 2 below are required by law. You must answer both your county board of elections it can effectively be used to identify your
of the questions for your registration to be processed. signature.

Registering in Person Please see information on back of this form to learn how to
If you have a current valid Ohio driver’s license, you must provide that obtain an absentee ballot.
number on line 10. If you do not have an Ohio driver’s license, you must
provide the last four digits of your Social Security number on line 10. If WHOEVER COMMITS ELECTION FALSIFICATION IS
you have neither, please write “None.” GUILTY OF A FELONY OF THE FIFTH DEGREE.
FOLD HERE
I am: Registering as an Ohio voter Updating my address Updating my name
1. Are you a U.S. citizen? Yes No
2. Will you be at least 18 years of age on or before the next general election? Yes No
If you answered NO to either of the questions, do not complete this form.
3. Last Name First Name Middle Name or Initial Jr., II, etc.

4. House Number and Street (Enter new address if changed) Apt. or Lot # 5. City or Post Office 6. ZIP Code

7. Additional Mailing Address or P.O. Box (if necessary) 8. County (where you live) FOR BOARD
USE ONLY
SEC4010 (Rev. 6/14)
9. Birthdate (MO-DAY-YR) (required) 10. Ohio Driver’s
driver’sLicense
licenseNo.No.OROR 11. Phone No. (voluntary) City, Village, Twp.
Last Four
last 4 Digits
digits of Social
of Social SecurityNo.
Security no.
(oneform
(one formofofIDID required
required to listed
to be be listed or provided)
or provided)
12. PREVIOUS ADDRESS IF UPDATING CURRENT REGISTRATION - Previous House Number and Street Ward

Previous City or Post Office County State Precinct

School Dist.
13. CHANGE OF NAME ONLY Former Legal Name Former Signature

Cong. Dist.
14.
Date / /
I declare under penalty of Your Signature MO DAY YR
election falsification I am a Senate Dist.
citizen of the United States, will
have lived in this state for 30
House Dist.
days immediately preceding
the next election, and will be
at least 18 years of age at the
time of the general election.
 To ensure your information is updated, please do the following:
1. Print this form.
2. Complete all required fields.
3. Sign and date your form.
4. Fold and insert your form into an envelope.
5. Mail your form to your county board of elections. For your county board’s
address please visit www.OhioSecretaryofState.gov/boards.htm.
If you have additional questions, please call the office of the Ohio Secretary of State
at 877-SOS-OHIO (767-6446).

HOW TO OBTAIN AN OHIO ABSENTEE BALLOT

You are entitled to vote by absentee ballot in Ohio without providing a reason. Absentee ballot applications may
be obtained from your county board of elections or from the Secretary of State at:
www.OhioSecretaryofState.gov or by calling 1-877-767-6446.

OHIO VOTER IDENTIFICATION REQUIREMENTS

Voters must bring identification to the polls in order to verify identity. Identification may include current and valid
photo identification, a military identification, or a copy of a current (within the last 12 months) utility bill, bank
statement, government check, paycheck, or other government document, other than a notice of an election or a
voter registration notification sent by a board of elections, that shows the voter’s name and current address.
Voters who do not provide one of these documents will still be able to vote by providing the last four digits of the
voter’s Social Security number and by casting a provisional ballot pursuant to R.C. 3505.181. For more information
on voter identification requirements, please consult the Secretary of State’s website
at:www.OhioSecretaryofState.gov or call 1-877-767-6446.

WHOEVER COMMITS ELECTION FALSIFICATION IS GUILTY

OF A FELONY OF THE FIFTH DEGREE.