WeCare Healthcare & Associates

Referred By:*

Legal First and Last Name as it appears on your Social Security Card*

First NameLast Name

Date Of Birth*

Complete Social Security number to verify U.S. Citizenship*

Physical Address*

Street Address

Apt or Unit # (If Applicable)

CityState / Province

Postal / Zip Code

Mailing Address (If different from above)

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Marital Status*

If Married(Required) Complete the Section below: (Spouse Name,DOB, SSN)

Gender*

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Race*

Dependents as it appears on your 2022 tax return(Name,DOB,SSN):

Comments:

Estimated Annual Income*

Employer Name/Type of Work*

Employer Phone Number*

Upload Government ID*

Upload Other Documents such as Social Security Card & ETC

Would you be interested in receiving a phone call from our Agent to discuss dental and vision insurance options?

YesNo

I, (client name)*

give my permission to Joreca Rudd (NPN# 20735244) 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 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 following:

1. Searching for an existing Marketplace application;

2. Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace premiums;

3. Providing ongoing account maintenance and enrollment assistance, as necessary; or Responding to inquiries from the Marketplace regarding my Marketplace application.

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 by written consent.*

Joreca Rudd

NPN #20735244

8134169531

Jorecaw@gmail.com

Name of Client *

First NameLast Name

Phone Number*

Email Address*

Do you understand that if you’re not eligible for a $0 plan we will enroll you in the cheapest plan that is still affordable? (If you decide that you do not want this plan simply don’t pay the bill or call the insurance company to cancel.) *

YesNo

Signature*

"Meet our dedicated health insurance agent, Joreca Rudd, who specializes in providing comprehensive coverage for your clients healthcare needs. With a deep understanding of the insurance landscape, she is committed to finding the perfect plans that fit thier unique requirements. Whether they are an individual, or a family, she will guide them through the complex world of insurance, ensuring that they receive the most suitable coverage at the best value. Her expertise and personalized approach allow her to assess their specific needs, educate them on available options, and help them make informed decisions about their health insurance. With the guidance of her associate Joree Walton, you can rest assure that they will receive top-notch coverage for all of their healthcare needs, ensuring peace of mind and financial protection for them and their families." For more information: jaerudd@wecarehealth.site

WeCare Healthcare & Associates

Consent Form