Florida Healthy Kids

Family-Related Medical Assistance Application

* Marked fields are required.

Authorized Representative

You can give a trusted person permission to talk about this application with us, see your information, and act for you on matters related to this application, including getting information about your application and signing your application on your behalf. This person is called an “authorized representative.” If you ever need to change your authorized representative, contact the Marketplace. If you’re a legally appointed representative for someone on this application, indicate below.

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Certified Counselors

Complete this section if you’re a certified application counselor, navigator, agent, or broker filling out this application for somebody else.

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DO Include:

  • Your spouse
  • Your children under 21 who live with you
  • Your unmarried partner who needs health coverage
  • Anyone you include on your tax return, even if they don’t live with you
  • Anyone else under 21 who you take care of and lives with you

You DON’T have to include:

  • Your unmarried partner who doesn’t need health coverage
  • Your unmarried partner’s children
  • Your parents who live with you, but file their own tax return (if you’re over 21)
  • Other adult relatives who file their own tax return