Enroll Below In $0 - Low-Cost Health Insurance Plans

Low-Income
Self-Employed

Do you currently Have ACA Marketplace (Ambetter) Plan, Medicaid, or Medicare? *

Yes

First Name *

Last Name *

Phone *

Email *

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 your dependents names and date of births. *

Projected income for this year

Do you Use Tobacco Products? *

Yes

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.

HEALTH INSURANCE CONSENT AND ACKNOWLEDGMENT FORM

AGENT INFORMATION

Agent Name: Robert Lewis

NPN: 9755131

Email: [email protected]

Agent Name: Elizabeth Medeiros

NPN: 21286136

Email: [email protected]

Agent Name: Craig Bernstein

NPN: 2112539

Email: [email protected]

Agent Name: Chris Grzybowski

NPN: 17820955

Email: [email protected]

Agent Name: Chris Sullivan

NPN: 17187349

Email: [email protected]

APPLICANT ACKNOWLEDGMENTS & CONSENTS

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 the above-listed agents as my agents of record for all matters related to health insurance, including assistance with enrollment, policy changes, and claims. I understand that this consent can be revoked or modified at any time by providing written notice via email, postal mail, or in-person communication to the agents.

CONSUMER ACKNOWLEDGMENT OF HEALTH SHERPA NPN USE

I acknowledge that my enrollment may be submitted with a Health Sherpa National Producer Number. The potential Health Sherpa NPNs that may be appended to the enrollment are:

Robert Lewis: 9755131

Elizabeth Medeiros: 21286136

Craig Bernstein: 2112539

Chris Grzybowski: 17820955

Chris Sullivan: 17187349

I also understand that the enrollment remains accessible and serviceable by the selected agents as my representatives.

SCOPE OF APPOINTMENT

I understand that this appointment is valid for 12 months from the date of signing and will renew annually unless revoked.

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.

HIPAA AUTHORIZATION

I authorize my agents to access and share my protected health information (PHI) as needed for insurance enrollment, policy servicing, and claims assistance. This may include application details, policy status, claims data, and eligibility verification. This authorization follows HIPAA regulations and can be revoked in writing at any time via email, postal mail, or in person.

COMMUNICATION CONSENT (TCPA COMPLIANCE)

I consent to receive communications from my agents regarding health insurance options, benefits, and related matters through phone calls, emails, SMS messages, and other forms of communication. These communications may involve automated dialing systems, artificial/prerecorded voices, or other technology.

By submitting the survey, I acknowledge that I am providing express written consent under the Telephone Consumer Protection Act (TCPA) to receive such communications from my agents.

AI SYSTEMS COMMUNICATION CONSENT

I agree to receive AI-initiated communications via SMS, voice calls, or emails for purposes related to health insurance and related matters from the listed agents. I can opt out of such communications at any time by notifying the selected agents.

OPT-OUT INSTRUCTIONS

I may opt out of communications at any time by:

Replying STOP to SMS messages.

Emailing the selected agents:

Robert Lewis: [email protected]

Elizabeth Medeiros: [email protected]

Craig Bernstein: [email protected]

Chris Grzybowski: [email protected]

Chris Sullivan: [email protected]

Calling or notifying the agents in writing.

PURPOSE OF COMMUNICATIONS

I understand that communications may be sent regarding:

Health insurance enrollment

Policy updates

Claims assistance

CMS Marketplace compliance

NO GUARANTEES

I understand that while my agents will strive to provide the best possible benefits based on my circumstances, no specific outcomes are guaranteed.

DATA PROTECTION AND PRIVACY

My personal and income-related data will be treated in compliance with relevant data protection laws and will remain confidential.

ADVERTISEMENTS AND MISLEADING INFORMATION

I confirm that I have not been influenced by misleading advertisements or false promises. All information provided during the enrollment process was transparent and accurate.

CMS REQUIREMENTS ACKNOWLEDGMENT

I acknowledge that CMS requires documentation of consent before applying for Marketplace coverage. I confirm that I have reviewed and verified the accuracy of my eligibility application.

RIGHT TO MODIFY OR REVOKE CONSENT

I understand that I may modify or revoke this consent at any time by providing written notification to the selected agents via email, postal mail, or in person.

DOCUMENTATION OF CONSENT AND ACCURACY VERIFICATION

By signing this form, I consent to apply for or enroll in health insurance coverage. I confirm that I have reviewed and verified the accuracy of my application information.

I understand that this document will be retained for a minimum of 10 years to comply with CMS and TCPA requirements. I acknowledge that this retention period ensures my records are available for compliance verification and dispute resolution.

AUTOMATIC PLAN RE-ENROLLMENT REQUEST

I request automatic re-enrollment in my current plan for the next Plan Year Renewal. Additionally, I authorize my agents to enroll me in a better plan if one becomes available that offers improved benefits or cost savings compared to my current selection.

I understand that if a better plan becomes available, my agents may enroll me in it based on my current eligibility and needs.

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

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