ACA Questionnaire
Full Name
First Name
Last Name
Email
example@example.com
County
Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Projected household income for 2025
Family/Household Members (Note: all family member you have on your taxes).
*
Please list all doctors, with their specialties, that ANYONE in your family sees.
Example: Tom Smith-Cardiologist, Susan Smith-Pulmonologist, etc
Please list ALL hospitals (and locations) that you and your family utilize.
Example: St. Lukes South, etc
Please list ALL pharmacies you and your family use.
Example: Walgreens Roe Blvd
Please List Your Medications Below. List the Name (Example: Atorvastantin), the dosage (Example: 1, 85mg tablets); the Frequency (Example: Once a day); and the Refill Rate (Examples: "monthly" or "as needed")
Submit
Should be Empty: