Carpenter Collective - Health Insurance Client Intake Form

1

Welcome!

2

Welcome!

3

Primary Head of Household Name* This field is required.Based on who is the primary tax filer

Prefix

First Name

Middle Name

Last Name

Suffix

4

Please confirm you have received, reviewed, and eSigned the Personal Identity Information Consent Form * This field is required.Sent Via Email

YESNO

5

Email

example@example.com

Confirm Email

6

Birthdate of Primary Head of Household* This field is required.

7

Primary Head of Household Social Security Number Required to search and add client’s account

Click next if you need to create an account

8

Anyone seeking coverage a smoker? * This field is required.Separate names with commas

9

Primary Head of Household ZipCode

10

Do you currently have a State or Federal Healthcare Marketplace Account?* This field is required.

Get Covered NJ

Pennie

Georgia Access

Virginia’s Insurance Market Place

Healthcare.gov (Federal)

Not Sure

I Do Not

Other

11

Do you have a Plan type preference?* This field is required.Click link to review plan types: https://www.healthcare.gov/choose-a-plan/plan-types/

HMO

EPO

PPO

POS

HSA Compatible

No Preference

Not Sure; Need more information

12

Will you be eligible for Medicare in the near future?* This field is required.

Yes

No

Not Sure

13

Is your COBRA coverage ending, if so why?* This field is required.

COBRA coverage is ending for others reasons

I am choosing to end my COBRA coverage early

COBRA coverage was declined during/after 60 day election period

I do not have COBRA coverage

Not Sure

14

Do you have a spouse and/or dependents that you file on YOUR tax returns?* This field is required.Applications are submitted per Tax Household

Yes

No

15

Age of spouse and/or dependents that need coverage and are filed on your tax returns:Separate Ages with Commas

Spouses and/or dependents applying for coverage must provide identity and income info.

16

Number of spouse and/or dependents that DON’T need coverage and are filed on YOUR tax returns:Separate Ages with Commas

Spouses and/or dependents NOT applying for coverage DO NOT have to provide identity and income info.

17

How often do you and those seeking coverage receive medical care per year?* This field is required.

1 to 3 times per year

4 to 8 times per year

8 or more times per year

18

How often do you and those seeking coverage take prescriptions per month?* This field is required.

0 to 3 times per month

4 to 8 times per month

8 or more times per month

19

Upload Doctor(s) Names/Medical Groups and their addressesEX: Primary Care, Specialist, Dentist or etc.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Click NEXT to type this information in instead

20

Upload Prescription(s) and Dosage(s)

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Click NEXT to type this information in instead

21

Upload Prior Insurance Carriers and/or Lost Coverage LettersEX: Medicaid Denial Letter, Prior Insurance Card or etc.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Click NEXT to type this information in instead

22

Who was your most recent Health Insurance Carrier?* This field is required.Cigna, Keystone, Aetna or etc.

* If document was uploaded, Type N/A also

23

Please provide name of current Primary Doctor for you and those seeking coverage.* This field is required.Include Address and Separate with Commas

* If document was uploaded, Type N/A also

24

Please provide list of medications and dosages for you and those seeking coverage. * This field is required.Separate with Commas

Ex: Hydrochlorothiazide 30 mg * If document was uploaded, Type N/A also

25

Are you and those seeking coverage currently seeing any specialist?* This field is required.Example: Obgyn, Podiatrist, Therapist or etc.

Yes

No

26

Please provide name of current Specialist for you and those seeking coverage.* This field is required.Name of Doctor or Facility’s Name. Include Addresses and Separate with Commas

* If document was uploaded, Type N/A also

27

Will anyone need Dental Coverage also?* This field is required.

Yes

No

28

Who was your most recent Dental Insurance Carrier?* This field is required.

* If document was uploaded, Type N/A also

29

Please provide name of current Dentist for you and those seeking coverage.* This field is required.Dentist Name or Dentist Office Name. Include Addresses and Separate with Commas

* If document was uploaded, Type N/A also

30

Any major dental care needed?* This field is required.Root canal, crowns, braces, dentures, or etc.

Yes

No

31

Any Vision coverage needed?* This field is required.Example: Glasses, Contacts, LASIK Discounts

Yes

No

Other

32

Who was your most recent Vision Insurance Carrier?

* If document was uploaded, Type N/A also

33

Please provide name of current Vision Office for you and those seeking coverage.* This field is required.Include Address and Separate with Commas

* If document was uploaded, Type N/A also

34

Any major Vision/Eye Procedures needed?* This field is required.LASIK surgery, Lens Coatings, Cataract surgery, cyst removal or etc.

No

Other

35

What is your monthly budget for the coverage needed?* This field is required.

36

If you had to replace a provider with a covered in-network provider, who can be replaced?* This field is required.Example: Primary Care Doctor or Vison Office can be replaced if needed

37

Anything else important that needs to be taken into consideration?Switching jobs, eligible Medicare soon, dependents only need dental coverage, or etc.

39

Friendly Reminder:

Please bring income items below to meeting for Primary head of household, spouse if filing jointly and all dependents filed on your tax returns:

• Paystubs

• New Job or Contract Offer Letter

• Social Security or Pension Award Letters

• Unemployment Benefit Letter or etc.

For all of those in tax household seeking coverage, please keep these items handy also:

• Drivers License, Social Security Number, Permanent Resident Card, Citizenship Certificate, Passport and/or Work Visa.

• If applying for coverage and have a social security number, it will be needed to enroll in coverage.

• Bring Doctors/ Dentist/ Specialist names and addresses if not listed here

• Bring Prescriptions and Dosage if not listed here