If you are asked to send documents to verify the information on your application, please click on the appropriate topic below to find a list of acceptable documents.
If you do not have any of the listed documents, or are still not sure what to send in, please call Vermont Health Connect toll-free at 1-855-899-9600, Monday – Friday 8am to 4:30pm (except certain holidays).
See the complete and printer friendly list of acceptable verification documents for health programs.
To send us your documents, you can:
- Take clear photos of the documents and upload them to your account.
- OR, you can mail copies (not original documents) of these documents to:
Vermont Health Connect
280 State Drive
Waterbury, VT 05671-8100
INCOME
Below are common documents for different income types.
Job Income
- Most recent Tax Return including form 1040
- Pay stubs (Note: For Medicaid, you must send us pay stubs from the last 30 days for everyone in your household.)
- Letter from employer
- Wages and tax statement (W-2 form)
Self-Employment Income
- Most recent Tax return including form 1040 and schedules showing self-employment, such as Schedule C, E or F
- Most recent quarterly or year-to-date Profit and Loss statement
- Bookkeeping records including receipts for income, and receipts for ALL allowable expenses
Unearned Income
- Most recent Tax return (please include all forms and schedules)
- Social Security income documents, such as a recent letter/document from the Social Security Administration, or SSA-1099 form
- Pension or retirement income documents, such as a 1099-R form, or most recent retirement account statement
- Rental income documents, such as a 1099-MISC form, or lease agreement
- Interest income documents, such as a 1099-DIV form, a 1099-INT form, or a recent account statement
- Unemployment income documents, such as a statement or letter form the Department of Labor detailing current benefits, or a 1099-G form
U.S. CITIZENSHIP
- U.S. passport
- State-issued enhanced driver's license (available in Michigan, New York, Vermont, and Washington)
- Certificate of Naturalization (N-550/N-570)
- Certificate of Citizenship (N-560/N-561)
- Document from federally recognized Indian tribe that includes your name and the name of the federally recognized Indian tribe that issued the document, and shows your membership, enrollment, or affiliation with the tribe, such as:
- A Tribal enrollment card
- A Certificate of Degree of Indian Blood
- A Tribal census document
If you don’t have any of the documents listed above, you can send in two (2) documents – one from each list below.
List 1
(provide one of these document plus a document from List 2):
- U.S. public birth certificate
- U.S. Citizen Identification Card (I-197 or the prior version I-179)
- Final adoption decree showing the person’s name and U.S. place of birth
- U.S. medical record from a clinic, hospital, physician, midwife or institution showing a U.S. place of birth
- Military record showing a U.S. place of birth
- Federal or State census record showing U.S. citizenship or U.S. place of birth
- School record showing the child’s name and U.S. place of birth
- Religious record showing U.S. place of birth recorded in the U.S.
- U.S. life, health or other insurance record showing U.S. place of birth
- Consular Report of Birth Abroad (FS-240, CRBA)
- Certification of Report of Birth (DS-1350)
- Certification of Birth Abroad (FS-545)
- U.S. Civil Service Employment Record showing employment before June 1, 1976
- Northern Mariana Card (I-873)
- Documentation of a foreign-born adopted child who received automatic U.S. citizenship (IR3 or IH3)
AND
List 2
(provide one of these documents that has a photograph or other information, like your name, age, race, height, weight, eye color, or address, plus a document from List 1:
- Driver's license issued by a State or Territory or ID card issued by the Federal, state, or local government
- School identification card
- A clinic, doctor, hospital, or school record, including preschool or day care records (for children under 19 years old)
- U.S. military card or draft record or Military dependent’s identification card
- U.S. Coast Guard Merchant Mariner card
- Voter Registration Card
- (2) documents containing consistent information that proves your identity, like employer IDs, high school and college diplomas, marriage certificates, divorce decrees, property deeds, or titles
IMMIGRATION STATUS
- Permanent Resident Card, “Green Card” (I-551)
- Arrival/Departure Record (I-94/I-94A)
- Employment Authorization Card (I-766)
- Refugee Travel Document (I-571)
- Certification from U.S. Department of Health and Human Services (HHS) Office of Refugee Resettlement (ORR)
- Temporary I-551 Stamp (on Passport or I-94/I-94A)
- Machine Readable Immigrant Visa (including temporary I-551 language)
- Foreign passport (including I-551 stamp or I-94 Arrival/Departure Record)
- Certificate of Eligibility for Nonimmigrant Student Status (I-20)
- Certificate of Eligibility for Exchange Visitor Status (DS-2019)
- Reentry Permit (I-327)
- I-797
- Verification of Release (VOR) form or card
RESIDENCY
- Current driver’s license
- State ID
- Mortgage payment receipt
- Mortgage deed showing primary residency
- Lease agreement
- Utility bill
- Government mail (SSA statement, DMV notice, etc.)
SOCIAL SECURITY NUMBER (SSN)
PROOF YOU'RE NOT ELEGIBLE, OR ENROLLED IN, MINIMAL ESSENTIAL COVERAGE
- Medicare
- Letter or statement from Medicare or the Social Security Administration stating that you are:
- No longer eligible for Social Security Disability Insurance (SSDI) benefits, and coverage has ended or will end in the next 90 days, OR
- Not eligible for (or enrolled in) premium-free Medicare Part A, OR
- Eligible for (but not enrolled in) Part A coverage that requires premium payments.
- A written statement describing why you are not eligible for, or enrolled in, premium-free Medicare Part A.
- Letter or statement from Medicare or the Social Security Administration stating that you are:
- Peace Corps
- Letter from the Peace Corps with the expiration date for any previous health coverage or a letter stating never had this type of coverage.
- A written statement describing why you are not eligible for, or enrolled in, health coverage through Peace Corps, or that you were never eligible for, or enrolled in, health coverage through the Peace Corps.
- TriCare
- Letter or statement from TRICARE that:
- Shows the expiration or un-enrollment date of previous health coverage, OR
- Confirms ineligibility for health coverage, OR
- Shows that you are eligible for but not enrolled in a TRICARE program that’s not considered qualifying health coverage such as:
- TRICARE Reserve Select,
- TRICARE Retired Reserve,
- TRICARE Young Adult (Prime and Select), and
- Continued Health Care Benefit Program
- Letter, statement, or other document indicating a major life event (like divorce) that would make you ineligible for TRICARE coverage.
- A written statement describing why you are not eligible for, or enrolled in, premium-free TRICARE
- Letter or statement from TRICARE that:
- Veterans Administration
AMERICAN INDIAN/ALASKAN NATIVE STATUS
- Tribal Enrollment/Membership Card from a federally recognized tribe
- Document issued by the Bureau of Indian Affairs (BIA) recognizing the applicant as American Indian/Alaska Native
- Authentic document from a federally recognized tribe declaring membership
- Document issued by IHS indicating individual is/was eligible for IHS services as an American Indian/Alaska Native
- U.S. American Indian/Alaska Native tribal enrollment or sharehold documentation
INCARCERATION
- Official release papers from the institution or Department of Corrections
- Parole papers
- Pay stubs
- Federal, state, or local benefit letter
- Clinic, doctor, or hospital records for services provided
- Cell phone or Utility bill (showing only your name)
- Rent receipts (showing only your name)
- Lease (must be an active lease where you are currently residing)
- Bank or credit card statement showing transaction history (showing only your name, but not a joint account)