Citizen 6765 Bedienungsanleitung PDF herunterladen (Seite 4)

Visit MAhealthconnector.org or call 1-877 MA ENROLL (1-877-623-6765)

TTY: 1-877-623-7773, Monday to Friday, 8:00 a.m. to 6:00 p.m.

Questions?

4 of 7

STEP 2

Tell us about anyone else who needs health or dental insurance coverage.

(continued)

PERSON 3

First name Middle name Last name Sufx Relationship to Person 1

Social Security number (SSN) Date of birth (month/day/year) Is Person 3



Male?



Female?

Does Person 3 have the same home and mailing address as Person 1?



Yes



No If no, list address:

Home address (Not PO box) Unit or apartment number

City State ZIP code

Mailing address Check here



if same as home address.

Unit or apartment number

City State ZIP code

Does Person 3 need health coverage?



Yes



Does Person 3 need dental coverage?



Yes



If yes, has Person 3 had dental insurance within the last 12 months?



Yes



If Person 3 needs health or dental coverage, answer all the questions below. If not, go to Person 4 or Step 3.

Is Person 3 a U.S. citizen or U.S. national?



Yes



If Person 3 is not a U.S. citizen or U.S. national, is he or she lawfully present in the U.S.?



Yes



If yes, write the immigration document type _______________________________________________________

For more information on acceptable immigration documents, go to MAhealthconnector.org

and write the immigration document ID number ______________________________________________________________

Is Person 3 living in Massachusetts?



Yes



If yes, does he or she plan to stay in Massachusetts?



Yes



If no, does he or she plan to move to Massachusetts?



Yes



Is Person 3 in jail or prison?



Yes



No If yes, is he or she (check one below)



Convicted. What is your expected release date? (month/day/year) ___ ___ /___ ___ /___ ___ ___ ___



Not convicted. (For example: conned only, awaiting trial)

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