Marketplace ACA Health Insurance Application form

How did you find out about us? (We need their name OR organization please)*

First NameLast Name

Legal First Name on Social Security Card*

First Name

Legal First and Last Name on Social Security Card

Legal Last Name on Social Security Card*

Last Name

Phone Number*

Please enter a valid phone number.

Emergency Contact Name and Phone Number

Date of Birth*

Date

Email*

example@example.com

Preferred Method of Communication*

Social Security Number*

Gender:

MaleFemale

Gender*

Street Address*

Apartment / Unit #

City*

In which State do you reside?*

Zip Code*

What COUNTY (not country) do you reside in? *

What doctor/provider do you want your insurance to cover?

Are you going to a treatment program? If so, please tell us which one

What prescription medications do you want your insurance to cover?

What is your expected taxable income for the year? (if you are self employed, what is your income after business expenses)? *

What type of work do you do or plan on doing? *

What is the name of your employer if you have one?

Address

Street Address

Street Address Line 2

CityState

Zip Code

Are you married or single (according to your TAXES)?*

MarriedSingle

Spouse*

Are you claiming any children/dependents on your taxes?*

Dependents*

DO YOU HAVE ANY DEPENDENTS ON YOUR 2024 TAXES? Spouse, children, etc. If YES, please list their LEGAL NAME, DATE OF BIRTH, AND SOCIAL of each one below:

NAME MUST MATCH SOCIAL SECURITY CARD

Are you a US citizen?*

YESNO

Please fill out*

Do you have health insurance currently?*

YESNO

Are you currently on Medicaid, Medicare, SSI, Disability, etc.?*

YESNO

Have you experienced any of these life events within the past 60 days?*

Change in household (marriage, divorce, birth/adoption, or death in the family)Lost health coverage (job-based, individual, student, Medicare, Medicaid, CHIP, or turning 26 off family plan)Were released from incarcerationChanged residence (temporary or permanent)Became a U.S. citizen or lawful residentGained tribal membership or Alaska Native shareholder statusStarted or ended AmeriCorps serviceNone of these (may not be eligible for special enrollment)

Change in household*

Loss of Coverage*

Released from incarceration*

Changed Residence*

Became U.S. Citizen or Permanent Resident*

Have you filed your taxes for 2024?*

YESNO

Do you need dental insurance?*

NODentalDental AND Vision

By typing your name here, you understand and agree to the statement above about representation and choosing us as your agent of record:*

Signature*

All information entered is encrypted and secure. All questions must be answered. If it is not applicable, please enter NA. If you need further assistance, you may contact the office at 770.224.6825 -Thank you.

CONSENT OF REPRESENTATION

I voluntarily give consent to this stated representation to guide me with the health insurance process through the ACA healthcare exchange/marketplace.

I understand all information submitted is protected under the Federal regulations governing Confidentiality and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. pts 160 & 164, and cannot be disclosed without written consent unless otherwise provided for by the regulations. I also understand that I may revoke this consent at any time, in writing, except to the extent that action has been taken in reliance on it.

I understand that by receiving insurance through the ACA healthcare exchange/marketplace, I am using tax credits to offset the cost of the chosen health insurance plan. Should I have tax-related questions I will consult with my tax professional and I will not hold my representation liable in any way.

I give my permission to my representation to serve as the health insurance agent or broker for myself and my entire household, if applicable, for purposes of enrollment in a QUALIFED health plan offered on the Federally Facilitated Marketplace.

In the event I am not able to contact my representation, or if the representation is unable to contact me, I risk losing my policy as my repesentation must receive consent each and every time an application is touched for viewing/updating/enrollment/renewal, etc.

By consenting to this agreement, I authorize the above mentioned representation to view and use the confidential information provided by me in this electronic form or by phone only for one or more of the following:

Searching for an existing marketplace application
Completing an application for eligibility and enrollment in a marketplace qualified healthplan or other government insurance affordability programs, such as Medicaid and CHIP or advanced tax credits to help pay for marketplace premiums
Providing ongoing account maintenance and enrollment assistance, as necessary
Responding to inquiries from the marketplace regarding my application

I understand that the representation will not use or share my personally indentifiable information (PII) for any purpose other than those listed above. The representation will insure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above.

I confirm that the information I provide for the entry on my marketplace eligibility and enrollment application will be true to the best of my knowledge.
I confirm that I have reviewed my completed application and that all information is accurate.

I understand that I do not have to share additional personal information about myself or my health with my agent beyond what is required on the application for eligibility and enrollment purposes. I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by contacting my agency/agent or revoking it through my health sherpa dashboard.

NAME OF WRITING AGENCY:
HOPEDEALERS WORLDWIDE NPN#20651087

Writing Agents:
PRINCIPAL AGENT: NADINE PSAREAS - NPN#2036170
AGENT: AMBER ROBINSON- NPN#20822293
AGENT: JULIA EMORY - NPN#20800372
AGENT: JORDAN PORTER - NPN#20886930
AGENT: PETER PSAREAS - NPN#21086452
AGENT: DELROZA HUGHES: NPN# 21105290
AGENT: MISTY BAYLIN - NPN#21231040
AGENT: LORIN LANNING- NPN#20603210

hopedealersworldwide@gmail.com
770.224.6825 OR 470.288.3201

Hopedealers Worldwide