Forms & Tax Information

Application Forms and Documents
CoverME.gov Paper Application for Individuals (PDF)
  • This application is for individual Mainers to see whether they qualify for affordable private insurance, tax credits to help them afford coverage, or if they are potentially eligible for MaineCare.
CoverME.gov Paper Application for Families (PDF)
  • This application is for Maine families to see whether they qualify for affordable private insurance, tax credits to help them afford coverage, or if they are potentially eligible for MaineCare.
CoverME.gov Paper Application Instructions Document (PDF)
  • This document provides additional instructions to help consumers fill out the individual and family paper applications.
CoverME.gov Authorized Representative Form (PDF)
  • This form allows consumers to designate an authorized representative who can act on their behalf. Authorized representatives can sign and submit applications for consumers, sign and submit recertification forms, receive copies of notices and other written communications from CoverME.gov, and represent the consumer at a fair hearing.
American Indian and Alaska Native Application Addendum (PDF)
  • This addendum to the individual and family paper applications is for American Indian and Alaska Native applicants to provide additional information that can help determine if they are eligible for additional benefits.
Health Coverage from Jobs & Employer Coverage Tool Application Addendum (PDF)
  • This addendum to the individual and family paper applications is for applicants with at least one member of their household who is eligible for health coverage through a job.
DHHS Authorization to Release Information Form (PDF)
  • This form allows the Maine Department of Health and Human Services to release your personal identifiable information to a consumer or another person they designate.
How to Enroll in Health Insurance Through CoverME.gov (PDF)
  • This instructional document provides a basic overview of the process for Maine consumers to enroll in health insurance coverage through CoverME.gov.
Verification Forms and Documents
Documents Needed for Verification Informational Sheet (PDF)
  • This document provides guidance about the types of documents CoverME.gov accepts for identity verification and to resolve the numerous types of Data Matching Issues (DMIs).
Income Attestation Form (PDF)
  • This form is for consumers who do not have other documentation to attest to their current income or change in income.
Small Business Health Options Program Forms
Small Business Health Options Program (SHOP) Application for Employers (PDF)
  • This form allows small businesses to apply for an official determination of eligibility for the Small Business Health Options Program (SHOP) and the Small Business Health Care Tax Credit. Eligible small businesses can enroll through a broker or directly through the sponsoring health insurance carrier.
Appeals Forms

To request an appeal, fill out the Appeals Request Form below and mail it to the address listed.

Once you file an appeal, you will receive a formal ‘Acknowledgement of Appeal Notice’ based on your Marketplace communication preference which confirms your intent to appeal and includes additional information about the appeals process. CoverME.gov will then mail you a notice telling you when a hearing before an independent Administrative Hearings Officer will occur in your case. This is a hearing that you must attend, whether it is conducted virtually or in-person.

The hearing will remain scheduled unless you contact CoverME.gov at 1-866-636-0355 (TTY: 711) to cancel it. At your hearing, you can testify, have others testify for you, and submit documents. CoverME.gov representatives can ask you (or other people who testify) questions. CoverME.gov representatives can also submit documents and testimony. You can ask any agency witness questions too. The Administrative Hearings Officer will then make a decision. You will get a notice explaining the decision by US mail. It will also tell you what to do if you do not agree with it.

Appeals Request Form (PDF)
  • This form is for consumers who wish to appeal an eligibility determination from CoverME.gov and have an administrative hearing on the matter.
Appeals Withdrawal Form (PDF)
  • This form is for consumers who wish to withdrawal their appeal of an eligibility determination from CoverME.gov and not have an administrative hearing on the matter.
Tax Information

Your 1095 tax form for 2021 will be sent to you by HealthCare.gov. You can contact them for more information.