P4 Applicant Intake Form

Name Name*

First NameMiddle NameLast NameSuffix

Date of Birth*

Date

Gender*

Tobacco User?*

Email*

example@example.com

Phone*

Please enter a valid phone number.

Secondary Phone*

Please enter a valid phone number.

Different Name Appears on Social Security Card?*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Use different mailing address*

Social Security #

Preferred Spoken Language

Preferred Written Language

Marketplace Notices

Best Method of Contact

I will be applying for coverage for myself*

I want t see if I may qualify for lower csts through the Federal Marketplace*

Do you plan to file a federal income tax return for 2024?

Will you be claimed as a dependent on someone else's tax return?

Did your household income change by more than 7.5% over the past year?

Marital Status

Filing a joint tax return for 2024?

Employer Name

First NameLast Name

Configurable list*

1. Were any of these people found not eligible to get Medicaid or Children's Health Insurance Program (CHIP) in the past 90 days? Or, were any of them found not eligible for Medicaid or CHIP due to their immigration status in the last four years?*

2. Are you a member of a federally recognized tribe, or an Alaska Native corporation shareholder?*

3. Are you or any of your dependents enrolled in other health coverage?*

4. Are you or any of your dependents currently eligible for group coverage, including COBRA?*

5. Will you or any of your dependents be eligible for group coverage in 2023, including COBRA?*

1. Did you or any of your dependents recently lose health coverage?

2. Are you or any of your dependents losing health coverage in the next 60 days?

3. Did you or any of your dependents recently get married?

4. Have you or any of your dependents recently been adopted, placed for adoption or placed for foster care?

5. Have you or any of your dependents recently gained eligible immigration status?

6. Have you or any of your dependents recently moved?

7. Have you or any of your dependents been recently released from incarceration?

Additional Comments

I understand that Plan IV will complete my health plan application and if, chosen by me, provide my financial information on my behalf to determine if I am eligible to purchase plans on the Federal Marketplace.*

No one applying for health coverage on this application is incarcerated (detained or jailed)..*

I know that 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 1-800-318-2596. TTY users should call 1-855-889-4325. I understand that a change in my information could affect my eligibility for member(s) of my household.*

Permission for information submitted

By submitting this application, you represent that you have permission from all of the people whose information is on the application to both submit their information to the Marketplace and receive any communications about their eligibility and enrollment.

Privacy Act Statement – effective 10/1/2013You, you are authorized to collect the information on this form and any supporting documentation, including social security numbers. (See the Patient Protection and Affordable Care Act (Public Law No. 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (Public Law No. 111-152), and the Social Security Act).

The information provided about you and the other individuals listed on this form will be used to assist you in determining eligibility for (1) enrollment in a qualified health plan through the Federal Health Insurance Marketplace, (2) insurance affordability programs (such as Medicaid, CHIP, advanced payment of the premium tax credits, and cost-sharing reductions), and (3) certifications of exemption from the individual responsibility requirement. As part of that process, your information provided on the form will be verified. We will communicate with you or your authorized representative, and eventually provide the information to the health plan you select so that they can enroll any eligible individuals in a qualified health plan or insurance affordability program.

CMS will also use the information provided as part of the ongoing operation of the Marketplace, including activities such as verifying continued eligibility for all programs, processing appeals, reporting on and managing the insurance affordability programs for eligible individuals, performing oversight and quality control activities, combatting fraud, and responding to any concerns about the security or confidentiality of the information.

While providing the requested information (including social security numbers) is voluntary, failing to provide it may delay or prevent your ability to obtain health coverage through the Marketplace, advanced payment of the premium tax credits, cost-sharing reductions, or an exemption from the shared responsibility payment. If you don’t have an exemption from the shared responsibility payment and you don’t maintain qualifying health coverage for three months or longer during the year, you may be subject to a penalty. If you don’t provide correct information on this form or knowingly and willfully provide false or fraudulent information, you may be subject to a penalty and other law enforcement action.

In order to verify and process applications, determine eligibility, and operate the Marketplace, CMS will need to share selected information that it receives outside of CMS, including the following:

1. Other federal agencies, (such as the Internal Revenue Service, Social Security Administration, and Department of Homeland Security), state agencies (such as Medicaid or CHIP), or local government agencies. CMS may use the information you provide in computer matching programs with any of these groups to make eligibility determinations, to verify continued eligibility for enrollment in a qualified health plan or Federal benefit programs, or to process appeals of eligibility determinations. Information provided by applicants won’t be used for immigration enforcement purposes;
2. Other verification sources including consumer reporting agencies;
3. Employers identified on applications for eligibility determinations;
4. Applicants/enrollees, and authorized representatives of applicants/enrollees;
5. Agents, Brokers, and issuers of Qualified Health Plans, as applicable, who are certified by CMS who assist applicants/enrollees;
6. CMS contractors engaged to perform a function for the Marketplace; and
7. Anyone else as required by law or allowed under the Privacy Act System of Records Notice associated with this collection (CMS Health Insurance Exchanges System (HIX), CMS System No. 09-70-0560, as amended, 78 Federal Register, 8538, March 6, 2013, and 78 Federal Register, 32256, May 29, 2013).

This statement provides the notice required by the Privacy Act of 1974 (5 U.S.C. § 552a(e)(3)). You can learn more about how CMS handles your information at: https://www.healthcare.gov/how-we-use-your-data

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 that I may be subject to penalties under federal law if I intentionally provide false or untrue information.

I have read and understand the Privacy Act Statement**

Current Date

Date

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Signature*

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About Your Dependents

Dependents

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Optional Questions

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