Health Intake Form
In order to find accurate options for you & your family, a few basic questions will need to be answered for all potential applicants:
Sign in to Google to save your progress. Learn more
Email *
Full Legal Name & Date of Birth
 *
Are you married? *
Yes I'm Married: Spouse Full Name & Date of Birth
Spouse Social Security Number 

If you choose NOT to provide your Social Security Number today, you will have 90 days to provide your social to the Marketplace. If they do not receive your information within 90 days. The Marketplace will terminate your insurance We'll send reminders via email, text and phone calls once you've received your ID cards

Name of Employer for Spouse
Spouse Expected Income Per Month (Be Accurate - Income Will Be Verified By Healthcare.gov)
Do you want to apply for a subsidy to pay for your insurance?
 *
MAIN APPLICANT Phone Number *

MAIN APPLICANT Address

 *
MAIN APPLICANT County *
MAIN APPLICANT Social Security Number

If you choose NOT to provide your Social Security Number today, you will have 90 days to provide your social to the Marketplace. If they do not receive your information within 90 days. The Marketplace will terminate your insurance We'll send reminders via email, text and phone calls once you've received your ID cards

 *
Job Seeking

If making less than $1100/mo, I agree I am looking for a job making minimum wage or better
 *
Most Recent Employer
 *
Expected Income Per Month (Be Accurate - Income Will Be Verified By Healthcare.gov)
 *
Does Anyone Use Tobacco? If so who? *

Do you currently have Medicare, Medicaid, an employer policy or VA benefits? (you will NOT qualify for Obamacare subsidy if you qualify for Medicaid/Medicare/employer or VA plan}.

 *
How do you file your taxes?  *

I attest that from this day forward Erica T. Walker, NPN (18867762), will be the agent of record for my healthcare.gov insurance plan with the marketplace and will only be replaced by another agent if written notice is submitted to her.

 *

Do you understand that if you’re not eligible for a $0 plan we will enroll you in the cheapest plan that is still affordable? (If you decide that you do not want this plan simply don’t pay the bill or call the insurance company to cancel.)

 *
How many dependents do you claim?
 *
Full Name & Date of Birth for Each Person you want to include on your plan *
How is your general health?  *
Any health conditions? If so, what treatment is recommended and/or needed? If nothing, please respond "N/A"
 *
Prescriptions being taken, reason for use, and dosage
 *
Approximate Height & Weight for any adult on the policy
 *
When we find you the right solution, what is your tentative start date? (Immediately Tomorrow/Next Week/Next Month/etc...)
 *
MM
/
DD
/
YYYY
What is your specific budget range/what are you currently paying or what will your COBRA be? *If you're currently on an employer plan, the employer is paying 50% or more of your monthly premiums

Current Premium?

Specific Budget range? 
 *
Any must have Doctors, Pediatricians, Specialists, Dentist, Optometrist, etc.? Our goal is to make sure they are in-network with whichever carrier you pick. If none, please respond "N/A"
 *
Do you need maternity coverage?
 *
Do you need Yearly Routine Wellness Exams?
 *
Would you like Dental and Vision Insurance?
 *
Do you need Mental Health Visits?
 *
Do you have life insurance?  
 *
Would you in interested in seeing what options are available?
 *
Required
Were you referred by someone? If so please provide their name.
What is a good day/time that I can answer your questions so that you can simply then pick the carrier/plan that best fits your needs.
 *
I give permission to apply for free health insurance!

AGREEMENTS

Please read the attestations below and sign if you agree.

I agree to have my information used and retrieved from government data sources for this application. I have consent for all people I’ll list on the application for their information to be retrieved and used from government data sources.

I understand that I’m required to provide true answers and that I may be asked to provide additional information, including proof of my eligibility for a Special Enrollment Period if I qualify. If I don’t, I may face penalties, including the risk of losing my eligibility for coverage. Renewal of coverage

To make it easier to determine my eligibility for help paying for coverage in future years, I agree to allow the Marketplace to use my income data, including information from tax returns, for the next 5 years. The Marketplace will send me a notice, let me make any changes, and I can opt out at any time.

TAX ATTESTATION

I understand that I’m not eligible for a premium tax credit if I’m found eligible for other qualifying health coverage, like Medicaid, the Children’s Health Insurance Program (CHIP), or a job-based health plan. I also understand that if I become eligible for other qualifying health coverage, I must contact the Marketplace to end my Marketplace coverage and premium tax credit. If I don’t, the person who files taxes in my household may need to pay back my premium tax credit.

I understand that because the premium tax credit will be paid on my behalf to reduce the cost of health coverage for myself and/or my dependents: I must file a federal income tax return for the 2022 tax year.

I MUST FILE A FEDERAL INCOME RETURN FOR THE 2024 TAX YEAR.

If I’m married at the end of 2024, I must file a joint income tax return with my spouse. I also expect that: No one else will be able to claim me as a dependent on their 2023 federal income tax return. I’ll claim a personal exemption deduction on my 2023 federal income tax return for any individual listed on this application as my dependent who is enrolled in coverage through this Marketplace, and whose premium for coverage is paid in whole or in part by advance payments of the premium tax credit.

IF ANY OF THE ABOVE CHANGES

I understand that it may impact my ability to get the premium tax credit. I also understand that when I file my 2023 federal income tax return, the Internal Revenue Service (IRS) will compare the income on my tax return with the income on my application. I understand that if the income on my tax return is lower than the amount of income on my application, I may be eligible to get an additional premium tax credit amount. On the other hand, if the income on my tax return is higher than the amount of income on my application, I may owe additional federal income tax.

PLEASE READ ATTESTATIONS BELOW BEFORE YOU SIGN AND SUBMIT YOUR APPLICATION:

I know that I must tell the program I’ll be enrolled in if information I listed on this application changes. I know I can make changes in my Marketplace account or by texting Erica T. Walker at 866-455-1290. I know a change in my information could affect eligibility for member(s) of my household.

If anyone on your application is enrolled in Marketplace coverage and is later found to have other qualifying health coverage (like Medicare, Medicaid, or CHIP), the Marketplace will automatically end their Marketplace plan coverage. This will help make sure that anyone who’s found to have other qualifying coverage won’t stay enrolled in Marketplace coverage and have to pay full cost.


 *

I’m signing this application under penalty of perjury, which means I’ve provided true answers to all of the questions to the best of my knowledge. I know I may be subject to penalties under federal law if I intentionally provide false information.

 *
I have read and agree to the terms above
 *
Required
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms