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.

Date of Birth*

Date

Email*

example@example.com

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, or specific treatment center do you want to MAKE SURE is covered by this insurance?

What is your expected adjusted gross income for the year? (if you are self employed, what is your profit after expenses)?

What type of work do you do or do you 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)?*

Married (include spouse's NAME and DATE OF BIRTH below!)Single

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

Do you have health insurance currently?*

YESNO

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

YESNO

Have you been married, divorced, had a child, released from incarceration or lost a job in the past 60 days?

Do you need dental insurance?

YESNO

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

With the guidance of licensed insuance brokers and certified behavioral health professionals, Hopedealers Worldwide assists those impacted by the disease of addiction and their family and loved ones, whether in crisis or in recovery, obtain affordable health insurance in order to obtain preventative and necessary medical treatment and appropriate care.

I voluntarily give consent of representation to Hopedealers Worldwide (licensed brokers - Nadine Psareas, Amber Robinson, Julia Emory, Jordan Porter, Peter Psareas, Misty Baylin, or Delroza Hughes) to guide me with the health insurance process through the ACA healthcare exchange/marketplace.

I understand all information submitted to Hopedealers Worldwide 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 Hopedealers Worldwide liable in any way. Hopedealers Worldwide does offer a specialized tax professional to our clients at a very reduced rate.

I understand that Hopedealers Worldwide is a 501c3 non-profit organization that provides Integrative Behavioral Health Counseling and Coaching among a variety of other support services for those in the community and no person benefits financially or is compensated from this service. Any commissions generated are given to the 501c3 non profit to serve the community. Helping and guiding people with ACA marketplace insurance is a 100% community outreach.

I give my permission to Hopedealers Worldwide (Nadine Psareas, Amber Robinson, Julia Emory, Jordan Porter, Peter Psareas, Misty Baylin, or Delroza Hughes - licensed brokers) 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 Hopedealers Worldwide Agency, or if the agency is unable to contact me, I risk losing my policy as Hopedealers Worldwide 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 agency and agents 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 agency/agents will not use or share my personally indentifiable information (PII) for any purpose other than those listed above. The agent 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

hopedealersworldwide@gmail.com
770.224.6825 OR 470.288.3201

Hopedealers Worldwide

OPEN ENROLLMENT WILL END JANUARY 15 FOR A FEBRUARY 1 START DATE UNLESS YOU HAVE A SPECIAL ENROLLMENT QUALIFIER