Health Care Enrollment Form

Health Care Enrollment Form:

**If your application is approved please allow 2-4 weeks for your ID cards to arrive!

**By Filling out this form, I am consenting to have my information checked to see if I Qualify for a Premium Tax Credit Healthcare Plan!

First Name *

Middle Initial

Last Name *

Birth Date * +

SEX *

Male

Female

SSN *

ADDRESS *

City, Sate, *

Zipcode *

Phone number *

Email address *

Employment *

What type of work? *

Employers Phone # *

Annual Income *

Does the client have insurance through their job? *

Yes

No

Is the client currently enrolled in health coverage? *

Yes

No

Do you plan to file a federal income tax return for 2023? *

Yes

No

Are you married? *

Yes

No

Adding A Spouse *

Spouse Name

Birth Date +

SSN

Spouse Employer and Annual Income

Employee Phone #

Adding Dependents *

Dependent 1 Full Name

DOB +

Sex

SSN

Dependent 2 Full Name

DOB +

Sex

SSN

Dependent 3 Full Name

DOB +

Sex

SSN

Dependent 4 Full Name

DOB +

Sex

SSN

Upload Your Government ID

Referred By: *

Notes:

Consent Form:
Acknowledgements - Patient Protection & Affordable Care Act (PPACA) Assistance I acknowledge that I have engaged the assistance of an independent Health Insurance Agent (Agent) licensed in the state of Florida, certified by the Centers for Medicare & Medicaid Services (CMS), to assist me in the enrollment process for the Affordable Care Act (ACA) through the Healthcare.gov (Marketplace) website. I do not currently have Medicare or Medicare and I was not offered any sort of incentive or anything of value to enroll. In doing so, I understand and agree that all information supplied by me is accurate to the best of my knowledge. If proof of income or any other information is required by the Marketplace, it is my sole responsibility to provide it. I understand that any changes included but not limited to my information, income, health plan, etc. made by me can affect the eligibility/status of my health insurance plan. I also understand that I should be reporting my accurate adjusted gross income (estimate if hours fluctuate), not the estimate that maximizes the amount of premium tax credit for which I may be eligible when completing or updating an application for eligibility. By signing this Acknowledgement, I provide my signature, expressly authorizing Florida Blue, their agents or partner companies to contact me at the number and address provided with insurance quotes or to obtain additional information for such purpose, via live/prerecorded/autodialed calls, text messages and/or emails for a period of 3 years. I understand that my signature is not a condition of purchasing any property, goods, or services and that I may revoke my consent at any time. I also understand that I can contact my Agent for any questions pertaining to my policy and/or any changes that I would like to discuss. I consent to my Agent calling the Marketplace Call Center to ask about the status of a Marketplace enrollment as needed, up to once a year with approval from the applicant on the line. Questions regarding your application can be made to: Phone: (877) 989-9693 Email: info@tsdigitalmedia.com Marketplace Phone: (800) 318-2596 *****The Customer acknowledges receipt of HIPPA Privacy Information at time of enrollment and agrees to allow Agent access to Healthcare.gov as needed to secure and maintain my health insurance policy throughout the initial term of the plan and subsequent renewals. Permission To Review I am voluntarily authorizing and giving consent to Theresa Peoples (my Agent), as a Licensed Florida Health Insurance Agent, to review my health insurance enrollment now and annually, and advise me using all reasonable efforts, that I have made a sound choice for the current policy term and any subsequent policy terms. I understand the main roles of my agent are to advise me on how I can become eligible for certain plans on the Marketplace, build an understanding of my needs as a client, answer any questions I may have about my plan, and assist me in securing coverage. I understand that my Agent has permission to conduct a search for the consumer application using approved Classic Direct Enrollment/Enhanced Direct Enrollment websites in the Marketplace, assist with completing an eligibility application, assist with plan selection and enrollment, and assist with ongoing account/enrollment maintenance. I understand that this consent will last indefinitely unless I as the client revoke it. I understand that my legal name matches my signature below and I do know the name of my agent. My signature below also confirms my understanding of all the above. *

Your Signature *

clear