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Important Message: Open Enrollment for 2022 health and dental plans is coming! Learn how the American Rescue Plan Act lowers health insurance for Vermonters. Find out when and how to apply.

Documentation

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.

To send us your documents, 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
 

If you still are 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).

U.S. Citizenship

  • U.S. passport
  • Certificate of Naturalization (N-550/N-570)
  • Certificate of Citizenship (N-560/N-561)
  • State-issued enhanced driver's license (available in Michigan, New York, Vermont, and Washington)
  • 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. Documents you can provide include:
  • A Tribal enrollment card
  • A Certificate of Degree of Indian Blood
  • A Tribal census document
  • Documents on Tribal letterhead signed by a Tribal official

If you don’t have any of the documents listed above, you can send in two (2) documents – one from each list below.

You can provide one of these documents:

  • U.S. public birth certificate
  • Consular Report of Birth Abroad (FS-240, CRBA)
  • Certification of Report of Birth (DS-1350)
  • Certification of Birth Abroad (FS-545)
  • U.S. Citizen Identification Card (I-197 or the prior version I-179)
  • Northern Mariana Card (I-873)
  • Final adoption decree showing the person’s name and U.S. place of birth
  • U.S. Civil Service Employment Record showing employment before June 1, 1976
  • Military record showing a U.S. place of birth
  • U.S. medical record from a clinic, hospital, physician, midwife or institution showing a U.S. place of birth
  • U.S. life, health or other insurance record showing U.S. place of birth
  • Religious record showing U.S. place of birth recorded in the U.S.
  • School record showing the child’s name and U.S. place of birth
  • Federal or State census record showing U.S. citizenship or U.S. place of birth
  • Documentation of a foreign-born adopted child who received automatic U.S. citizenship (IR3 or IH3)

 AND

One of these documents that has a photograph or other information, like your name, age, race, height, weight, eye color, or address:

  • Driver's license issued by a State or Territory or ID card issued by the Federal, state, or local government
  • School identification card
  • U.S. military card or draft record or Military dependent’s identification card
  • U.S. Coast Guard Merchant Mariner card
  • Voter Registration Card
  • A clinic, doctor, hospital, or school record, including preschool or day care records (for children under 19 years old)
  • (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

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Immigration status

  • Reentry Permit (I-327)
  • Permanent Resident Card, “Green Card” (I-551)
  • Refugee Travel Document (I-571)
  • Machine Readable Immigrant Visa (with temporary I-551 language)
  • Temporary I-551 Stamp (on Passport or I-94/I-94A)
  • Foreign passport
  • Arrival/Departure Record (I-94/I-94A)
  • Arrival/Departure Record in foreign passport (I-94)
  • Certificate of Eligibility for Nonimmigrant Student Status (I-20)
  • Certificate of Eligibility for Exchange Visitor Status (DS-2019)
  • Employment Authorization Card (I-766)
  • Notice of Action (I-797)

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Income

  • Wages and tax statement (W-2)
  • Pay stubs (Note: To get Medicaid, you must send us pay stubs from the last 30 days for everyone in your household.)
  • Letter from employer
  • Cost of living adjustment letter and other benefit verification notices
  • Lease agreement
  • Copy of a check paid to the household member
  • Bank or investment fund statement
  • Document or letter from Social Security Administration (SSA)
  • Form SSA 1099 Social Security benefits statement
  • Court records for alimony and records of agency through which alimony is paid
  • Legal documents that establish amount and frequency of alimony
  • Self-employment ledger
  • Letter from government agency for unemployment benefits
  • Document or letter from Social Security Administration
  • Proof of tribal income
  • 1099-MISC
  • 1099-G - Certain Government Payments
  • Military Leave and Earnings Statement
  • Proof of gambling winnings
  • Bank statement
  • Agricultural income certificate
  • Financial Aid transcript form for current semester/school year

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Self-Employment

  • Most recent quarterly or year-to-date profit and loss statement
  • Tax return including form 1040 and schedules showing self-employment, such as C or F 1065 Schedule K1 with Schedule E
  • Tax return
  • Bookkeeping records Receipts for ALL allowable expenses
  • Bank Statements (personal & business) and cancelled checks
  • Signed time sheets and receipt of payroll, if you have employees

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Unearned Income

  • Annuity statement
  • Statement of pension distribution from any government or private source
  • Worker’s compensation letter
  • Prizes, settlements, and awards, including court-ordered awards letter
  • Proof of gifts and contributions
  • Proof of inheritances in cash or property
  • Proof of strike pay and other benefits from unions
  • Sales receipts or other proof of money received from the sale, exchange or replacement of things you own
  • Interests and dividends income statement
  • Loan statement showing loan proceeds
  • Royalty income statement or 1099-MISC
  • Proof of bonus/incentive payments (like a letter of bank statement showing deposit)
  • Proof of severance pay
  • Pay stub indicating sick pay
  • Letter, deposit, or other proof of deferred compensation payments
  • Pay stub indicating substitute/assistant pay
  • Pay stub indicating vacation pay
  • Proof of residuals
  • Letter, deposit, or other proof of travel/business reimbursement pay

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Incarceration

  • Official release papers from the institution or Department of Corrections
  • Parole papers
  • Unexpired state ID, driver’s license, work ID, or passport
  • Pay stubs
  • Federal, state, or local benefit letter
  • Clinic, doctor, or hospital records for services provided
  • Medical claim explanation of benefits provided
  • School record/schedule showing enrollment (like for college students)
  • Bank or credit card statement showing transaction history (showing only your name, but not a joint account)
  • Military records
  • Utility bill (showing only your name)
  • Lease (must be an active lease where you’re currently residing)
  • Signed notarized statement from the individual with alleged false incarceration inconsistency showing that you’re living in the community and includes your name, date of birth, and address
  • Written statement from someone within the community which shows your name, date of birth, address, phone number, your relationship with the person with alleged false incarceration inconsistency (if it’s not you), and that you’re present and participating within the community
  • Rent receipts (showing only your name)

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Indian Status

  • Tribal Card
  • Document issued by BIA recognizing an individual as American Indian/Alaska Native
  • Authentic document from a tribe declaring membership for an individual
  • Certificate of Degree of Indian Blood
  • Certificate of Indian status card
  • I-872 American Indian Card
  • 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 documentation
  • Document that shows a relationship to an individual listed on an Indian Census Roll

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Proof You're not Eligible for, or Enrolled in, Minimal Essential Coverage

  • Medicare
    • Letter or statement from Medicare or the Social Security Administration stating that you are: 
      • 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.
  • Veterans Administration
    • Letter from the Veterans Administration that states expiration date of previous health coverage.
    • A written statement describing why you are not eligible for, or enrolled in, health coverage through the Veterans Administration
  • 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 Coverage

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Residency

  • Driver’s license
  • State ID
  • Mortgage payment receipt
  • Mortgage deed showing primary residency
  • Lease agreement
  • Utility bill
  • Government mail (SSA statement, DMV notice, etc.)

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Social Security Number (SSN)

  • Social Security card
  • Tax form(s)
  • Benefit or income statement from Social Security containing your SSN
  • Pending application for an SSN
  • Letter from Social Security stating that you’re not eligible for an SSN or are only eligible for a non-work SSN
  • Letter stating that you refuse to obtain an SSN for established religious objection

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Identity

You can provide one of these documents:

  • Driver’s license issued by state or territory
  • School identification card
  • Voter identification card
  • U.S. military draft card or draft record
  • Identification card issued by the federal, state, or local government
  • U.S. passport or U.S. passport card
  • Certificate of Naturalization (Form N-550 or N-570) or Certificate of U.S. Citizenship (Form N-560 or N-561)
  • Permanent Resident Card or Alien Registration Receipt Card (Form I-551)
  • Employment Authorization Document that contains a photograph (Form I-766)
  • Military dependent's identification card
  • Native American tribal document
  • U.S. Coast Guard Merchant Mariner card
  • Foreign passport, or identification card issued by a foreign embassy or consulate that contains a photograph

OR

If you don't have a copy of the documents listed above, you can provide two of these documents:

  • Birth certificate
  • Social Security card
  • Marriage certificate
  • Divorce decree
  • Employer identification card
  • High school or college diploma (including high school equivalency diplomas)
  • Property deed or title

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