ACA Subsidy Application Review

ACA Subsidy Application Review

Verification of subsidy application information
Important

This form must be filled out each time any change is made to a Subsidy Application. There are no exceptions.
Client or authorized representative:*
Client or authorized representative email:*
example@example.com
Date of birth:*

MonthDayYear
Date
Date of the review:*
Marketplace Application ID # *
Assisting agent:*
If anyone on your application is enrolled in Marketplace coverage and is later found to have other qualifying health coverage (like Medicare, Medicaid, or the Children's Health Insurance Program (CHIP)), the Marketplace will automatically end their Marketplace plan coverage. This will help make sure that anyone who’s found to have other qualifying coverage won’t stay enrolled in Marketplace coverage and have to pay full cost.*

YesNo
I must tell the program I'll be enrolled in if information I listed on this application changes. I know I can make changes in my Marketplace account or by calling the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325). I can also call my agent to help me. I know a change in my information could affect eligibility, subsidy amounts and premiums for member(s) of my household.*

YesNo
I'm signing this application under penalty of perjury, which means I've provided true answers to all of the questions to the best of my knowledge. I know I may be subject to penalties under federal law if I intentionally provide false information. I agree that the income information on the application is correct, provided by me and that I have reviewed it with my agent.*

YesNo
Signature*

Clear
Should be Empty:

ACA Subsidy Application Review

Important