Helpful Forms

Forms and worksheets that you may need to include with your application or Healthy Kids Silver or Buy-In enrollment information can be downloaded from this page.

Application Forms

Employment Verification Form
This form can be filled out by an employer as a verification of wages earned.

Self Employment Form
Use this form if you are self-employed and have not yet filed a tax return.

Identification Form for Children Under 16
This form can be completed by your child’s school or day care to prove identity.  

*Note: Children 16 or older need to send a photo ID.

Enrollment Forms

Healthy Kids Silver Enrollment Form
This form is used to enroll in the Healthy Kids Silver program after your child has been determined eligible for that program. When sending in this form, please remember to select a Primary Care Provider for your child and include your first month’s premium payment.

Healthy Kids Buy-In Enrollment Form
This form is used to enroll in the Healthy Kids Buy-In program after your child has been determined eligible for that program. When sending in this form, please remember to select a Primary Care Provider for your child and include your first month’s premium payment.

Accounting Forms

Healthy Kids Silver Automatic Premium Withdrawal
If you are enrolled in the Healthy Kids Silver program, use this form to authorize NH Healthy Kids to automatically withdraw your payments from your bank account.

Healthy Kids Buy-In Automatic Premium Withdrawal
If you are enrolled in the Healthy Kids Buy-In program, use this form to authorize NH Healthy Kids to automatically withdraw your payments from your bank account.

Renewal Forms

Renewal Application – English
This application is used to complete your annual renewal for Healthy Kids Gold or Healthy Kids Silver.

Renewal Application – Spanish
Esta aplicacion es usada para completar su renovacion anual de Healthy Kids Gold o Healthy Kids Silver.

Employment Verification Form 

This form can be filled out by an employer as a verification of wages earned.

Self Employment Form
Use this form if you are self-employed and have not yet filed a tax return.

Identification Form for Children Under 16

This form can be completed by your child’s school or day care to prove identity.  

*Note: Children 16 or older need to send a photo ID.