Applications and Forms

Applications and Forms

• Account Request Form (PDF)
• Application for Health Coverage and Help Paying Costs - DHS-6696-ENG (PDF)
• Application for Health Coverage - DHS-6741 (PDF)

• Broker Case Status Request Form (Excel)
• Employer Health Coverage form-Appendix A (PDF) (for employees who enroll in individual coverage and whose employer offers small group coverage)

Application Changes and Special Enrollment Periods

Please see the Helping Consumers section for information on these and other topics.