APPLY FOR $0 HEALTH COVERAGE SUBSIDY USING TAX CREDITS

Are you on Medicare or Medicaid? *

Yes

Do you currently have a marketplace health plan? *

Yes

First Name *

Last Name *

Email *

Phone *

Mailing Address - No P.O Box

Address *

City *

State *

Zip Code *

Trusted Form Ping Url

IP Address

Trusted Form Cert Url

Main Applicant Date of Birth: *

Gender *

Main applicant's Social Security (We need this to verify your marketplace application) *

Please select your Marital Status *

Please enter your Spouse's First Name *

Please enter your Spouse's Last Name *

Spouse Gender *

Spouse Date Of Birth *

Do you want to enroll spouse as well? *

Spouse SSN: *

Do you have tax dependents (typically children)? *

Number of Tax Dependents (Typically children) *

Do you wish to enroll your dependents as well? *

Please list all your tax dependents Full Names and Date of Births - make sure the information provided is accurate *

Projected income for this year

Disqualify Lead

Disqualify

Most Recent Employer Name or Company Name if Self Employed *

Projected annual income for this year based on household size: *

Employment status *

Signature *

Clear

Invalid signatures (dots, marks, etc.) may result in application denial. Please provide a clear, valid signature.

Prescriptions if any

Primary Doctor Name

Health Insurance Consent And Acknowledgment Form Agent Information: Agent Name: Elizabeth Medeiros Email: [email protected] NPN: 21286136 Agent Name: Craig Bernstein Email: [email protected] NPN: 2112539 Personal And Income Information Accuracy: I confirm that all personal and income-related information I have provided is accurate and true to the best of my knowledge. This information will be used to determine my eligibility for health insurance and any potential subsidies. Agent of Record Consent: I appoint Elizabeth Medeiros and Craig Bernstein as my agents of record for all matters related to health insurance. This includes assisting with enrollment, policy changes, and claims. I understand that this consent can be revoked or modified at any time by notifying either agent in writing. Scope of Appointment: I understand that this appointment is valid indefinitely unless I specify a different duration or choose to revoke it earlier. The agents will notify me annually to confirm if I wish to continue the appointment. Special Enrollment Period (SEP) Acknowledgment: I acknowledge that certain life events may qualify me for a Special Enrollment Period (SEP) and that my agents can assist me in applying for coverage during such times. Communication Consent: I consent to receive communications from Elizabeth Medeiros and Craig Bernstein regarding health insurance options, benefits, and related matters through phone calls, emails, or other forms of communication. I understand that I may opt out of these communications at any time. No Guarantees: I understand that while Elizabeth Medeiros and Craig Bernstein will strive to provide the best possible benefits and subsidies based on my circumstances, there are no guarantees regarding specific outcomes. Data Protection and Privacy: My personal and income-related data will be treated with the utmost privacy and used in compliance with all relevant data protection regulations. Advertisements And Misleading Information: I confirm that I have not been influenced by any misleading advertisements or promises. Elizabeth Medeiros and Craig Bernstein have committed to providing accurate and transparent information during the enrollment process. CMS Requirements Acknowledgment: I have been informed about CMS's requirements to document and maintain records indicating that I have provided consent prior to applying for or enrolling in Marketplace coverage. I also confirm that I have reviewed and verified the accuracy of my eligibility application information before its submission to the Marketplace. Documentation of this consent will be maintained for a minimum of 10 years and will be provided to CMS upon request. Right To Modify Or Revoke Consent: I understand that I have the right to modify or revoke any consent given at any point in time by notifying Elizabeth Medeiros or Craig Bernstein in writing. Documentation Of Consent And Accuracy Verification: By signing below, I provide my consent to apply for or enroll in health insurance coverage and confirm that I have reviewed and verified the accuracy of the application information. This form includes the date and time of my consent and confirmation, ensuring compliance with CMS documentation requirements. Automatic Annual Plan Renewal Enrollment: I also request that Elizabeth Medeiros and Craig Bernstein automatically re-enroll me in a plan for the next current Plan Year Renewal each year.

Application signature *

Clear

Invalid signatures (dots, marks, etc.) may result in application denial. Please provide a clear, valid signature.

I want The Agent of Record to choose the best available $0 plan in my area

I agree

Plan Name

Selected Plan Image

Plan Carrier Name

Plan ID

Plan type