Paper Applications

If you want to mail a paper application for Vermont Health Connect coverage, you can download and print PDF versions of the applications below. Paper applications can take time to process, and it may be faster to apply online or call the Vermont Health Connect Customer Service Center at 1-855-899-9600. You can also make an appointment to speak with an in-person assister near you.

If you are not sure how to fill in an application, please call our Customer Service Center toll-free at 1-855-899-9600. They are available Monday – Friday from 8 am to 4:30 pm.

If you’re not sure if you can get financial help paying for coverage, the Plan Comparison Tool can help. It will also give you side-by-side plan details to help you pick the plan that’s right for you. For full details for all Vermont Health Connect plans, you can also check our summaries of plan benefits and coverage by metal level.

TO AVOID DELAYS -

If you choose to fill in the paper application below and mail it to us, please make sure you have filled in every field before signing and mailing to:

Vermont Health Connect
280 State Drive
Waterbury, VT, 05671-8100

Applications for Health Coverage

Individual applications (with financial help):

• Application for Health Coverage and help paying costs (205ALLMED)
• NUEVA Solicitud enEspañol - Solicitud de Cobertura de Salud y Ayuda para el Pago de Costos (205ALLMED)
• Appendix A: Assistance Completing the Application (if applicable)
• Appendix B: American Indian or Alaskan Native Family Member (if applicable)
• Appendix C: Employer Coverage Tool (if applicable)

Individual Application (with NO financial help):

• Application for Health Coverage with NO Financial Help
• Appendix A: Assistance Completing the Application (if applicable)

A printer friendly version of your rights and responsibilities.