楊玫保險2021健保申請家庭狀況變更表 (Computer Version)

楊玫保險2021健保申請家庭狀況變更表

2021 Health Insurance Change Request Form
Name / 姓名 *

First Name Last Name
Email / 電子郵件
example@example.com
Phone Number / 電話 *

Area Code Phone Number
在2021年的申請中，你的家庭狀況沒有任何變動吗？ / Is there any change in your 2021 health insurance application compare to 2020? *

我的家庭狀況沒有任何變動 / My family situation has no change. 我的家庭狀況(如：地址、移民身份、收入、家庭成員等)有變動 / My family situation (such as: address, immigration status, income, family members) has change(s)。
请选择变化类型（*可多选）/ Please select changes (*multiple choices):

2020年有搬家，住址有變動/ My address has changed. 2020年移民身份有變動（如：有收到新的EAD卡或綠卡、有轉公民）/ Our immigration status have changed. 2021年預估收入有變動 / 2021 Income estimate will change 2020年家庭成員有變動 (如結婚離婚，新添小baby等)。/Family member have change in 2020.
請在下面填寫您的新住址/Please provide your new address
請上傳您新的移民身份文件/Please upload your immigration documents.

點擊這裡上傳文件 (Click here to Upload Document)

Cancel of
2021年預估收入多少？/ My family 2021 income estimate will be:
請選擇家庭成員變化（可多選）/ Please select family member(s) changes type:

增加家庭成員/Adding Family Member 刪減家庭成員 / Remove Family Member
请填写家庭新成员信息 / Please provide new family member(s) information: *
如需要删减家庭成员，请提供该成员名字 / Please provide name of family member need be removed on application.
其他變動，請說明 / Other changes
有家庭成員目前有Medicaid或Peachcare嗎？/ Does any family member(s) currently have Medicaid or Peachcare? *

有/Yes 沒有/No
請填寫有Medicaid或Peachcare的家庭成員(們)的名字 / Who have Medicaid or Peachcare?
最近三個月家裡有成員(如小孩）被Medicaid / Peachcare拒絕過嗎？/ Has any family member such as child(ren) been rejected with Medicaid or Peachcare in last 3 months? *

有/Yes 沒有/No
誰被 Medicaid or PeachCare 拒絕了? 什麼時候被拒的？/ Who was rejected? When? *
*公民或持有綠卡五年以上的19歲以下孩子，如果最近沒有被Medicaid/PeachCare拒絕過，健保中心根據家庭收入狀況，有可能將孩子的申請自動送入GA Medicaid/PeachCare Program.

Children under the age of 19 who are citizen or have held a green card for more than five years, if they have not been rejected by Medicaid/PeachCare recently, the health insurance center may automatically send the child's application to the GA Medicaid/PeachCare Program based on family income level.
签名

Clear
日期/Date

Month Day Year
Date Hour Minutes AM/PM Option
Should be Empty: