Health Intake JotForm

In order to streamline the process, I am asking you fill this form out so I already have most of your info. Please do so as accurately as possible as the system does know if there are errors with your Date of Birth, SSN, or Legal Name. Thank you for filling out the form, I will reach out to you at your selected time below or as soon as possible. Thank you!
Were you referred by someone?*

YesNo
Who referred you?*
Do you have Medicare, Medicaid, or are you offered Health Insurance through work?*

YesNo
If so, which?

Work Health InsuranceMedicaidMedicare
First Name Last Name*
Date of Birth*

MonthDayYear
Date
Sex / Gender*

MaleFemale
Citizenship*

CitizenPermanent ResidentGreen Card / Other
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Apartment or Building Number

CityState / Province

Postal / Zip Code
County*
Social Security Number*
SSN# are verified!
Employer*
Job Title / Position*
Income EX: $500 / Weekly*
Marital Status*

SingleMarried
How do you file Taxes*

SingleMarried / Jointly
Do you claim any Dependents on your taxes?*

YesNo
How many Dependents do you file on your taxes?*
Spouse Name*

First NameLast Name
Spouse Date of Birth*

MonthDayYear
Date
Spouse Phone Number
Please enter a valid phone number.
Spouse SSN*
Spouse Sex / Gender*

MaleFemale
Spouse Job*
Spouse Income EX: $500 / Weekly*
Dependent 1*

First NameLast Name
Dependent 1 Date of Birth*

MonthDayYear
Date
Dependent 1 SSN
Sex / Gender*

MaleFemale
Dependent 2*

First NameLast Name
Dependent 2 Date of Birth*

MonthDayYear
Date
Dependent 2 SSN
Sex / Gender*

MaleFemale
Dependent 3*

First NameLast Name
Dependent 3 Date of Birth*

MonthDayYear
Date
Dependent 3 SSN
Sex / Gender*

MaleFemale
Dependent 4*

First NameLast Name
Dependent 4 Date of Birth*

MonthDayYear
Date
Dependent 4 SSN
Sex / Gender*

MaleFemale
Dependent 5*

First NameLast Name
Dependent 5 Date of Birth*

MonthDayYear
Date
Dependent 5 SSN
Sex / Gender*

MaleFemale
Dependent 6*

First NameLast Name
Dependent 6 Date of Birth*

MonthDayYear
Date
Dependent 6 SSN
Sex / Gender*

MaleFemale
Gives permission to MarCayce Crosby (NPN 17381154) to serve as the health insurance agent or broker for myself and my entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally and/or State Facilitated Marketplace.

By consenting to this agreement, I authorize the above-mentioned Agent to view and use the confidential information provided by me in writing, electronically, or by telephone only for the purposes of one or more of the above.

I understand that the Agent will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The Agent will ensure 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 entry on my Marketplace eligibility and enrollment application will be true to the best of my knowledge. 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 in writing.
First and Last Name of Primary Household Contact and/or Authorized Representative *

First NameLast Name
I attest that all the information above is true and complete to the best of my knowledge.*

Clear
Todays Date*

MonthDayYear
Date
For your protection and mine please upload a photo of a legal US ID, Passport, or Green Card for verification purposes.*
By signing below you acknowledge that:*

You fully understand and accept the terms mentioned above.
Writing Agent: MarCayce Crosby

Agent NPN: 17381154

Phone: 855-786-2324 or 864-477-4850

Email: KC@JPFinancialgroupllc.com
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