Medical Insurance Application Forms
The following applications and appendices should be used to apply for health coverage and help paying costs through Maryland Health Connection when you are unable to access and fill out an online application. Please review to find the one that applies to you and your situation. Each application has an introductory page that provides helpful information to get started. Please also look at the appendices to see if any of them apply to you.
If you choose you can print the application, fill it out and send it to the address noted. Or you can save the file to your desktop and type your information into the fields using your computer. Once you have completed the form online, then print it off and mail it to the address noted.
Please call our free phone line at any time you need help in the process at 1-855-642-8572 or 1-855-642-8573 for assistance if you are hard of hearing or deaf.