Health Insurance Form 2016

2016 MHA Nation Health Insurance Application

Please fill out the form below to apply
If you have trouble filling out this online application, you may also call our Enrollment Department at 1-888-215-4628 to apply over the phone Monday thru Friday 8am-5pm CST.

PLEASE NOTE: Filling out this health insurance application form does NOT guarantee health insurance coverage. All information must be processed, verified and approved by MHA Nation. Information entered on this form will be sent directly to Tribal-Care Insurance enrollment department who will work in partnership with the appropriated MHA Nation office to finalize and approve all eligible enrollments.
Verification of Your Current Health Insurance:
Do you currently have any type of full coverage health insurance plan? For example: Health insurance through your job, Medicare Parts A&B, or Medicaid? Etc. *
Did you have an Assurant Health insurance policy through Tribal-Care Insurance last year in 2015? *
Attestation *

By checking this box, I attest that the answers to the questions above is true to the best of my knowledge.
PLEASE SELECT NEXT TO CONTINUE

We apologize, at this time the health insurance plan chosen by the Tribe is only offered to members who DO NOT have access to full health insurance coverage. If you believe you have a unique situation or have further questions please do not hestitate to call us at 888-215-4628. Thank you.

2016 MHA Nation Health Insurance Application Continued....
NOTE: All questions without an asterick * next to it are optional and are not required to be answered in order to submit your application for the health plan being offered to MHA Nation members by the Three Affiliated Tribes.
Are you an enrolled MHA Member? *
Which Segment do you vote in? *
Full Name *

First Name Middle Name Last Name
What is your Gender? *
Date of Birth *

Month Day Year Date Picker Icon
Social Security Number (SSN) *

Mailing Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *

Area Code Phone Number
Secondary Phone

Area Code Phone Number
E-mail
Do you smoke? *
What is your height? (Please select Feet and Inches in the dropboxes below)
Feet
Inches
What is your weight?
lbs
Do you have a spouse or children who will be on the plan with you? *
Other Available Healthcare Assistance Information:
STATE MEDICAID PROGRAM
Are you interested in finding out if you and/or your family members qualify for Medicaid?

Yes No I have already been denied by my states Medicaid program
NOTE: Medicaid and the Children’s Health Insurance Program (CHIP) provide free or low-cost health coverage to millions of Americans, including some low-income people, families and children, pregnant women, the elderly, and people with disabilities.

You may also click on this link to find out more information on your states Medicaid program eligibility and guidelines: https://www.healthcare.gov/lower-costs/
IHS
Do you currently utilize any IHS services?
Are you interested in learning more about the IHS services available to you?

Yes, please have an IHS facility in my area contact me. No
PLEASE SELECT NEXT TO CONTINUE

You have indicated there are more people in your household that will be on the plan with you. Please fill out the information below to continue:
Person #2 added onto your application:
What is the relationship to you of the person you would like to add? *
Is Person #2 an enrolled member of the MHA Nation?? *
Person #2 First Name
Person #2 Middle Name
Person #2 Last Name
Person #2 Gender? *
Person #2 Date of Birth *

Month Day Year Date Picker Icon
Person #2 Social Security Number (SSN) *
Person #2 Smoke? *
Do you have a third person to add onto your application? *
PLEASE SELECT NEXT TO CONTINUE

You have indicated there are more people in your household that will be on the plan with you. Please fill out the information below to continue:
Person #3 added onto your application:
What is the relationship to you of the person you would like to add? *
Is Person #3 an enrolled member of the MHA Nation?? *
Person #3 First Name
Person #3 Middle Name
Person #3 Last Name
Person #3 Gender? *
Person #3 Date of Birth *

Month Day Year Date Picker Icon
Person #3 Social Security Number (SSN) *
Person #3 Smoke? *
Do you have a fourth person to add onto your application? *
PLEASE SELECT NEXT TO CONTINUE

You have indicated there are more people in your household that will be on the plan with you. Please fill out the information below to continue:
Person #4 added onto your application:
What is the relationship to you of the person you would like to add? *
Is Person #4 an enrolled member of the MHA Nation?? *
Person #4 First Name
Person #4 Middle Name
Person #4 Last Name
Person #4 Gender? *
Person #4 Date of Birth *

Month Day Year Date Picker Icon
Person #4 Social Security Number (SSN) *
Person #4 Smoke? *
Do you have a fifth person to add onto your application? *
PLEASE SELECT NEXT TO CONTINUE

You have indicated there are more people in your household that will be on the plan with you. Please fill out the information below to continue:
Person #5 added onto your application:
What is the relationship to you of the person you would like to add? *
Is Person #5 an enrolled member of the MHA Nation?? *
Person #5 First Name
Person #5 Middle Name
Person #5 Last Name
Person #5 Gender? *
Person #5 Date of Birth *

Month Day Year Date Picker Icon
Person #5 Social Security Number (SSN) *
Person #5 Smoke? *
Do you have a sixth person to add onto your application? *
PLEASE SELECT NEXT TO CONTINUE

You have indicated there are more people in your household that will be on the plan with you. Please fill out the information below to continue:
Person #6 added onto your application:
What is the relationship to you of the person you would like to add? *
Is Person #6 an enrolled member of the MHA Nation?? *
Person #6 First Name
Person #6 Middle Name
Person #6 Last Name
Person #6 Gender? *
Person #6 Date of Birth *

Month Day Year Date Picker Icon
Person #6 Social Security Number (SSN) *
Person #6 Smoke? *
Do you have a seventh person to add onto your application? *
PLEASE SELECT NEXT TO CONTINUE

You have indicated there are more people in your household that will be on the plan with you. Please fill out the information below to continue:
Person #7 added onto your application:
What is the relationship to you of the person you would like to add? *
Is Person #7 an enrolled member of the MHA Nation?? *
Person #7 First Name
Person #7 Middle Name
Person #7 Last Name
Person #7 Gender? *
Person #7 Date of Birth *

Month Day Year Date Picker Icon
Person #7 Social Security Number (SSN) *
Person #7 Smoke? *
Do you have an eighth person to add onto your application? *
PLEASE SELECT NEXT TO CONTINUE

You have indicated there are more people in your household that will be on the plan with you. Please fill out the information below to continue:
Person #8 added onto your application:
What is the relationship to you of the person you would like to add? *
Is Person #8 an enrolled member of the MHA Nation?? *
Person #8 First Name
Person #8 Middle Name
Person #8 Last Name
Person #8 Gender? *
Person #8 Date of Birth *

Month Day Year Date Picker Icon
Person #8 Social Security Number (SSN) *
Person #8 Smoke? *
Do you have a ninth person to add onto your application? *
PLEASE SELECT NEXT TO CONTINUE

You have indicated there are more people in your household that will be on the plan with you. Please fill out the information below to continue:
Person #9 added onto your application:
What is the relationship to you of the person you would like to add? *
Is Person #9 an enrolled member of the MHA Nation?? *
Person #9 First Name
Person #9 Middle Name
Person #9 Last Name
Person #9 Gender? *
Person #9 Date of Birth *

Month Day Year Date Picker Icon
Person #9 Social Security Number (SSN) *
Person #9 Smoke? *
Do you have a tenth person to add onto your application? *
PLEASE SELECT NEXT TO CONTINUE

You have indicated there are more people in your household that will be on the plan with you. Please fill out the information below to continue:
Person #10 added onto your application:
What is the relationship to you of the person you would like to add? *
Is Person #10 an enrolled member of the MHA Nation?? *
Person #10 First Name
Person #10 Middle Name
Person #10 Last Name
Person #10 Gender? *
Person #10 Date of Birth *

Month Day Year Date Picker Icon
Person #10 Social Security Number (SSN) *
Person #10 Smoke? *
Do you have any other persons to add onto your application? *
PLEASE SELECT NEXT TO CONTINUE

We apologize, but you must be an enrolled MHA Nation member in order to apply for this health insurance plan. Please contact your local councilman office to find out more details on how you can become an enrolled MHA Nation member and how to register to vote. Thank you.

2016 MHA Nation Health Insurance Application -Submission Page-
You are almost done.......please sign below and click submit.
By signing below, I attest under penalty of perjury, that all information on this application is correct and true to the best of my knowledge.
Signature
Please click the submit button below to send your application to be processed. Thank you.

If you have more members to add to your health insurance application please contact us at 888-215-4628. Thank you

Should be Empty:

2016 MHA Nation Health Insurance Application

We apologize, at this time the health insurance plan chosen by the Tribe is only offered to members who DO NOT have access to full health insurance coverage. If you believe you have a unique situation or have further questions please do not hestitate to call us at 888-215-4628. Thank you.

2016 MHA Nation Health Insurance Application Continued....

Person #2 added onto your application:

Person #3 added onto your application:

Person #4 added onto your application:

Person #5 added onto your application:

Person #6 added onto your application:

Person #7 added onto your application:

Person #8 added onto your application:

Person #9 added onto your application:

Person #10 added onto your application:

We apologize, but you must be an enrolled MHA Nation member in order to apply for this health insurance plan. Please contact your local councilman office to find out more details on how you can become an enrolled MHA Nation member and how to register to vote. Thank you.

Please click the submit button below to send your application to be processed. Thank you.

If you have more members to add to your health insurance application please contact us at 888-215-4628. Thank you