Visit MAhealthconnector.org or call 1-877 MA ENROLL (1-877-623-6765)
or
TTY: 1-877-623-7773, Monday to Friday, 8:00 a.m. to 6:00 p.m.
Questions?
6 of 7
STEP 4
Read and sign this application.
I know that I am signing this application under penalty of perjury, which means I’ve provided
true answers to all of the questions to the best of my knowledge. I know that I may be subject to
penalties under federal law if I intentionally provide false or untrue information.
I know that I must tell the Massachusetts Health Connector if anything changes and is
different from what I wrote on this application. I can visit MAhealthconnector.org or call
1-877 MA ENROLL (1-877-623-6765) to report any changes. I understand that a change in my
information could mean that other members of my household no longer qualify for coverage.
I know that under federal law, discrimination is not permitted on the basis of race, color,
national origin, sex, age, sexual orientation, gender identity, or disability. I can le a complaint of
discrimination by visiting www.hhs.gov/ocr/oce/le.
I know that the information on this form will only be used to see if I, and others on the application,
qualify for health or dental insurance coverage and will be kept private, as required by law.
I understand that my information will be used to check my qualications for health or dental
coverage. The Connector will check my answers using information in electronic databases such
as the Social Security Administration and Department of Homeland Security databases. If the
information doesn’t match, I may need to send proof.
Sign this application.
The person who lled 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 A.
Signature Date (month/day/year)
STEP 3
American Indian or Alaska Native (AI/AN) family members
Are you or is anyone in your family an American Indian or Alaska Native?
Yes If yes, continue. If you have more people to include, make a copy of this page and attach.
No If no, go to Step 4.
AI/AN Person 1
First name Middle name Last name Sufx
Member of a federally recognized tribe?
Yes
No
If yes, tribe name
AI/AN Person 2
First name Middle name Last name Sufx
Member of a federally recognized tribe?
Yes
No
If yes, tribe name
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