Would you like to e-Sign your application? (An e-signature is the same thing as signing your name with a pen at the bottom of a paper form.)
If you select this option, you will receive a notice in the mail that you must sign and return to complete the application process. This notice will also include a listing of the income documentation and citizenship documentation, if applicable, that is needed to complete your application.
Please note: You must be an adult and have a social security number to e-Sign.
You are about to e-Sign this application. Basically, this is the same thing as signing your name with a pen at the bottom of a paper form.
I certify to the best of my knowledge that I understand my rights and responsibilities.
I authorize the release of my personal, financial, and medical information for the purpose of determining eligibility.
I understand I am required to report changes as stated on the Rights and Responsibilities page.
I understand that my situation is subject to verification from employers, financial sources and other third parties.
I certify that all information in this application is true and correct under penalty of perjury.
I understand that if I designated an authorized representative, I am allowing this person to get official information about this application, and to act for me on all future matters pertaining to this application.
An adult household member must e-Sign this application. Choose this individual from the dropdown box below and enter the required information of this individual to complete the e-Signature process.
Have you entered all of your information? If you want to make any changes, please make them now.
You may print a copy of this application for your records:
To complete this application you must hit 'Submit Application' below and mail us your income documentation and citizenship documentation, if applicable. Your application will be considered incomplete until the documents are received. Once the application is processed you will receive a notice in the mail that will tell you what documents are needed to complete your application and where to send them.
If you indicated that someone you are applying for is not a US citizen, you will have to send copies of their immigration documents. Your application will be considered incomplete until we receive copies of these documents. Once your application is processed you will receive a letter indicating what we need to complete the application process. This letter will also tell you how to submit those documents.
This application is for the Children's Health Insurance Program (CHIP), a health insurance program for uninsured children under the age of 19. If you have not entered any children please go back and enter them. If you were applying for coverage for adults please visit ChooseCapitalBlue.com
Did you enter income for all people living in your household that are receiving income? If not go back and finish entering income information.
You will have to send income documentation for any income being received and any deductions you listed.Your application will be considered incomplete until we receive copies of these documents. Once your application is processed you will receive a letter indicating what we will need to complete the application process. This letter will also tell you how to submit those documents.
We will process your application within 30 days. You may call 1.800.KIDS.101 (1.800.543.7101), TTY users 1.800.242.4816, Monday through Friday, 8:00 am to 6:00 pm, to check on the status of this application or with any other questions.
To complete your application
We will send you a letter requesting the extra information that we need to complete your application. The letter will explain how to submit this information. Please send us this information right away so we can complete the application process.
If your child is eligible for CHIP:
After we check your income and other information, we will notify you of your child's enrollment date.
If your child is eligible for low-cost CHIP, you will receive a bill that must be paid before CHIP coverage can begin.
You will receive your child's identification card approximately 10 days from the date he/she becomes eligible, as long as you have selected a Primary Care Physician for your child.
You can begin using your child's CHIP coverage on the "effective date" stated in the enrollment letter.
If your child is not eligible for CHIP:
We will notify you in writing to let you know why your child is not eligible.
If your child appears to be eligible for Medical Assistance, we will send your application to the County Assistance Office.
If your child is enrolled in CHIP:
Once a year, on the anniversary of your child's enrollment, eligibility will be reviewed. This process is called renewal. Each year, before your family's renewal date, letters will be sent requesting verification of income and other family information. If you do not provide the information needed, your child's CHIP coverage will end.
Paystubs - dated within the past 60 days of the application/renewal signature date.
Letter from the employer - Only acceptable if EMPLOYER DOES NOT PROVIDE PAYSTUBS-LETTER MUST INDICATE THAT and only acceptable if:
On employer letterhead or signed by employer
Hours worked per pay (if hourly wage given)
Amount earned per hour or GROSS amt per pay period
Length of pay period
If indication of OT - details are needed.
Business ledger from employer - must include the above info.
W2 (use box 18 per PID), 1099 form, tax return - Only Acceptable for:
Subcontractors - who do not claim as self-employment income (due to no out of pocket expenses)
Seasonal Works - need both W2 and 1099 (for UC)
1040 FEDERAL tax form with all schedules (INCLUDING K-1 FORM) from the previous calendar year - Mid April is the cutoff for determining which years return is acceptable (tax filing deadline).
A year-to-date Profit and Loss- ONLY ACCEPTABLE FOR NEW SELF-EMPLOYMENT BUSINESSES OR A DRASTIC CHANGE FROM PREVIOUS YEAR. If extension was filed for previous year's taxes, proof of the extension must be received. The profit and loss must include:
Time period covered (example - Today is 8/25 - profit and loss should be from 1/1 through 7/31)
Gross income earned in that period
Line item list of expenses for the period
Net profit figure for the period.
S Corp - 1040 tax form with all schedules AND the form K-1, also, Paystubs or business records.
C Corp - same as S Corp
NOTE a self declaration letter is NOT acceptable
UC/EUC' Website (www.dli.state.pa.us)- Must include (AVAILABLE Wednesday, Thursday and Friday)
Benefit Payment History
CURRENT CLAIM SUMMARY (shows EUC start date, weekly benefit rate, remaining balance and EUC end date.
Check Stubs - must show deduction or 'Weekly Benefit Rate'
Letter from lawyer showing gross amount received
Bank Statement - IF NO OTHER PROOF AVAILABLE
Check Stub - must show deductions
Bank statement - IF NO OTHER PROOF AVAILABLE
RETIREMENT / PENSION
Award letters - old letters okay to accept if amount still the same
Check Stubs - must show deductions
Bank Statement - IF NOT OTHER PROOF AVAILABLE
IRA income is only counted if it is received as a monthly distribution. Acceptable proof would be a bank statement or something else that shows it is received monthly. If the income is not received monthly it is counted as a lump sum and cannot be included.
Computerized payment - Child Support website
Letter from individual paying the support - must include the following:
Signed and dated
To whom the support or alimony is paid
For whom the support is paid
Amount of support paid
Frequency of payment
Bank statements LAST RESORT - has to show the words "CHILD SUPPORT"
A court order - Cannot be more than 1 year old. Unless verification that amount received is still the same. If the court order is printed from the Website and it shows that there are arrears, we must ask for print out of actual payments.
Award letters - FROM CURRENT YEAR
1099 form - ONLY ACCEPTABLE IF NO INCREASE APPROVED FOR CURRENT YEAR
A current copy of the check - for adults, must verify if there is a Medicare deduction.