If you prefer paper applications to the online application, Customer Support Center (toll-free at 1-855-899-9600), or a Navigator or Broker, you can download and print PDF versions of the appropriate application below.
To compare your options side-by-side before making your plan selection, visit our online Plan Comparison Tool or download our Plan Comparison Brochures. Read DVHA's Public Charge Fact Sheet to learn how healthcare can impact your immigration status.
If you are not sure what information to enter please call our Customer Service Center toll-free at 1-855-899-9600. They are available Monday – Friday from 8 am to 5 pm. Your information will be treated with complete confidentiality.
Paper Applications for Health Coverage
1. Complete the paper application that best fits your needs:
- To apply for help paying for Health Coverage costs complete the 205ALLMED by hand:
To apply for Health Coverage with no financial help complete the 205INFA by hand:
- Print a copy of the 205INFA or call 1-855-899-9600 and ask that one be mailed to you. Fill it out completely. Don't forget to sign and date it!
2. Mail your completed and signed application.
To avoid delays in processing your application, please make sure you have completed every question before signing and mailing to:
Vermont Health Connect
Application and Document Processing Center
280 State Drive
Waterbury, VT 05671-8100