Read and scroll down.
By signing below, you agree that you have reviewed the application details with your agent at MALM Life and Health Insurance Agency (Lorena Tomasini 8848368, Merlin Ana Lepigaasdato 588049, Leslie Tomasini 16930556) and attest to the following:
✔ The details provided in the eligibility application are accurate, and I have provided true answers to all of the questions to the best of my knowledge.
✔ I have been provided an explanation of the attestations at the end of the eligibility application.
Eligibility Application Attestations
If anyone on this application is eligible for Medicaid:
I’m giving to the Medicaid agency our rights to pursue and get any money from other health insurance, legal settlements, or other third parties. I’m also giving to the Medicaid agency rights to pursue and get medical support from a spouse or parent.
I’m signing this application under penalty of perjury, which means I’ve provided true answers to all the questions on this form to the best of my knowledge. I know that I may be subject to penalties under federal law if I intentionally provide false or untrue information.
I know that I must tell the Health Insurance Marketplace® within 30 days if anything changes (and is different than) what I wrote on this application. I can visit HealthCare.gov or call 1-800-318-2596 to report any changes. I understand that a change in my information could affect my eligibility as well as eligibility for member(s) of my household.
I know that under federal law, discrimination isn’t permitted on the basis of race, color, national origin, sex, age, sexual orientation, gender identity, or disability. I can file a complaint of discrimination by visiting hhs.gov/ocr/office/file.
I know that information on my application will be used only to determine eligibility for health coverage, help paying for coverage (if requested), and for lawful purposes of the Marketplace and programs that help pay for coverage.
We need this information to check your eligibility for help paying for health coverage if you choose to apply. We’ll check your answers using information in our electronic databases and databases from the Internal Revenue Service (IRS), Social Security, the Department of Homeland Security, and/or a consumer reporting agency. If the information doesn’t match, we may ask you to send us confirmation.