We need one adult in the family to be the primary contact person for your application.
This can be the person applying for coverage themselves and/or can be a person applying for a family member.
We keep all information private and secure, as required by law.
We use personal information only to check eligibility for health coverage.
If you need to apply for additional people in your family, you will need to complete an application for each person that you want to apply for.
You are not required to provide immigration status or a Social Security Number (SSN) for the primary contact person if that person does not need health coverage.
Primary Contact Person:
Mailing address (Required)
Home address (if different from Mailing Address)
16. Do you want to get the information about this application by email?
17. What is your preferred spoken or written language (if not English)?
Is someone helping you fill out this application?
Complete the following section if you are filling out this form on behalf of the primary contact person and/or applicant(s).
Otherwise, leave blank.
Information about person needing coverage
If you are the primary contact person completing this application for yourself,
enter all of your information and enter Self for Question 24.
27. Do you have a Social Security Number (SSN)?
c. If you have not applied for a Social Security Number, list the reason:
We need a SSN if this person wants health coverage and has an SSN.
We use SSNs to check information to see who’s eligible to receive help with health coverage costs related to COVID-19.
If you want help getting an SSN, call 1-800-772-1213 or visit socialsecurity.gov. TTY users should call 1-888-842-3620.
28. a. Are you a U.S. citizen?
(Born in U.S., child of U.S. citizen, or former alien now naturalized as a U.S. citizen)
b. Are you a U.S. national?
(Born in unincorporated U.S. Territory who elects to be a national, not a U.S. citizen)
If you answered YES to Question 28 a. or b., SKIP to Question 30.
29. If you aren’t a U.S. citizen or national, check here if you have eligible immigration status.
Enter your document type and ID number below. You can also include other immigration-related information in 29.c.
If you do not have this information with you, you can still submit the application and we
will contact you for any other information we need.
This will not hold up the processing of your application.
Examples include: Alien or I-94 number, name as it appears on an immigration document, SEVIS ID or expiration date, or other information.
d. Have you lived in the U.S. since 1996?
e. Are you, or your spouse or parent a veteran or an active-duty member of the U.S. military?
30. Have you been tested for COVID-19? (OPTIONAL)
If yes, enter the date of your earliest COVID-19 test (OPTIONAL) :
31. Are you currently enrolled in any health coverage?
Permission to Release Information
Would you like us to share information about this application with a member of your family or other person of your choice?
By completing this section, you can give permission for the following person to receive information about your application/case, but they won’t have the ability to act on your behalf like an authorized
representative. You also give SCDHHS permission to release information about this application to this additional person or organization.