Individual Application

Data Collection to Support Eligibility Determinations for Insurance Affordability Programs and Enrollment through Health Benefits Exchanges, Medicaid and CHIP Agencies (CMS-10440)

OMB: 0938-1191

IC ID: 205692

Documents and Forms

Document Name Document Type
Form CMS-10440 Individual Application Form and Instruction
CMS-10440 Application for Health Coverage & Help Paying Costs (Short Form) Att-B individual-short-form-clean-508-2 2025.pdf Form and Instruction
CMS-10440 Application for Health Coverage & Help Paying Costs Att-C marketplace-consumer-application-family-clean-508-2 2025.pdf Form and Instruction
CMS-10440 Application for Health Coverage (no cost help) Att-D marketplace-application-without-financial-assistance-clean-508.pdf Form and Instruction
CMS-10440 Electronic application. Att A.-Application PRA Electronic Application 022825 Clean.xlsx Form
CMS-10440 Application for Health Coverage & Help Paying Costs (Short Form) - Spanish Att-B individual-short-form-spanish-clean-2 2025.pdf Form and Instruction
CMS-10440 Application for Health Coverage & Help Paying Costs - Spanish Att-C marketplace-consumer-application-family-spanish-clean-2 2025.pdf Form and Instruction
CMS-10440 Application for Health Coverage (no cost help) - Spanish Att-D marketplace-application-without-financial-assistance-spanish-clean-2 2025.pdf Form and Instruction