2022 HealthConnect form

Step 1. Information about you

This should be the same number as found on line 7 of your IRS tax form 1040.

You must write the same number that you wrote on your application for Health Insurance Marketplace coverage.

HealthConnect will not pay the tobacco surcharge (extra fee) if you or anyone in your household uses tobacco.

Step 2. Your contact information

Step 3. Information about your health insurance

Step 4. Information about your health insurance premium subsidy

You must select the “Advance Payment” option in the Health Insurance Marketplace to be eligible for financial help from HealthConnect.

Step 5. Read and sign application

You must check ALL of the boxes to submit your application.