Fill out the intake form to see if you qualify for health insurance through the marketplace. List everyone that will be on your tax return for 2026, whether they are applying for coverage or not. The advanced premium tax credit (APTC) is calculated based on income and household size.

Earlene will reach out via text or email to schedule an appointment to complete your enrollment.

(Please check your spam folder if you don't see

an email in your inbox.)

First Name *

Last Name *

Phone *

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, and new product updates, among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt out.

Address *

Street Address

City

State

Country

Postal Code

County (reside) *

Is your mailing address the same as your street address? *

Mailing Address (If different)

Preferred time for follow-up call *

Who Referred You To Us?

Email *

Are you applying for yourself? *

Yes

Date of birth *

Social Security Number *

Sex *

Employment Status *

Employer Name

What do you estimate your total annual taxable household income to be in 2026? This cannot be $0. *

Martial Status *

Do you plan to file a federal income tax return for 2026? You don't have to file taxes to apply for coverage, but you'll need to file next year if you want to get a premium tax credit to help pay for coverage now. *

Yes

Do you have a spouse that needs coverage? *

Spouse/Significant Other First Name

Spouse Last Name

Spouse/Significant Other Date of Birth

Spouse's Social Security Number

Spouse Gender

Will you be claimed as a tax dependent by someone else for 2026? *

Yes

Will you claim any dependents on your taxes for 2026 *

Dependent 1 Full Legal Name

Dependent 1 Gender

Dependent 1 Date of Birth MM-DD-YYYY

Dependent 1 Social Security Number

Do you need to add another dependent?

Yes

Dependent 2 Full Legal Name

Dependent 2 Gender

Dependent 2 Date of Birth MM-DD-YYYY

Dependent 2 Social Security Number

Do your dependents need coverage?

Do You Have A 2nd Dependent?

Do you need to add a 3rd dependent?

Yes

Dependent 3 Gender

Dependent 3 Date of Birth MM-DD-YYYY

Dependent 3 Social Security Number

Do You Have A 3rd Dependent?

Do you need to add 4th dependent?

Yes

Dependent 4 Full Legal Name

Dependent 4 Gender

Dependent 4 Date of Birth MM-DD-YYYY

Dependent 4 Social Security Number

Do You Have A 4th Dependent?

Do you need to add a 5th dependent?

Yes

Dependent 5 Full Legal Name

Dependent 5 Gender

Dependent 5 Date of Birth MM-DD-YYYY

Dependent 5 Social Security Number

Do You Have A 5th Dependent?

Do you or anyone in your household applying for coverage have Medicare, Medicaid or VA coverage? *

Yes

I understand that if anyone on my application enrolls in a Marketplace health plan and is later found to have other qualifying health coverage (including Medicare, Medicaid, or CHIP), the Marketplace will automatically end their Marketplace health plan. *

Yes

I understand that any financial help I receive from the federal government through Advance Premium Tax Credits is connected to my taxes. I understand I may owe taxes, or receive more tax credit, if my income for the year is different than what I estimated. I agree to file federal income taxes (jointly if married) and report the amount of Advance Premium Tax Credits received on my Tax Return for any year I have federal financial help to lower premium costs. *

Yes

Are you a US Citizen? *

Are you an American Indian or Alaska Native? *

Yes

Are you currently incarcerated (detained or jailed)? *

Yes

Do you have anyone under the age of 19 living in your home? *

Yes

Are you pregnant?

Yes

I understand that my application will be used to evaluate eligibility for health coverage through Georgia Access or Georgia Department of Community Health. If I enroll in Medicaid, I acknowledge that the GA Division of Medical Assistance and Health Services can file a claim and lien against the estate of a deceased Medicaid beneficiary to recover all Medicaid payments for services received on or after age 55 Estate Recovery - I understand that estate recovery only applies to Medicaid and it is not applicable to enrollment in a health plan through Georgia Access. If anyone on this application enrolls in Medicaid, I’m giving the Medicaid agency the right to pursue and get any money from other health insurance, legal settlements, or other third parties. I’m also giving the Medicaid agency rights to pursue and get medical support from a spouse or parent. *

Yes

I understand that I have 30 days to notify the Marketplace of any change of information in this application. I will report any changes within this time period. I understand that changes in my income, household size, address or other details might affect my or my household's eligibility for specific benefits. I understand and will notify the Marketplace if my application information changes. *

Yes

By signing my name in the box below, I attest that 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. *

Yes

Signature *

Clear