Carpenter Collective - Health Insurance Client Intake Form

1

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

2

Before getting started, please click the link below to review and eSign your PII and PHI consent form.

We cannot move forward until this is completed.

Click to Sign Consent Form

3

Please confirm you have received, reviewed, and eSigned the Consent Form * This field is required.Link in Previous Slide

YESNO

4

Email

example@example.com

Confirm Email

5

Do you currently have a Healthcare Marketplace Account?* This field is required.May be State Based or through Federal Exchange Site/Partners

Yes

No

I don’t know

6

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

Click next if you need to create an account

7

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

8

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.

9

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.

10

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

No Preference

Not sure; Need more information

11

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

12

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

13

Any injuries or illness that require immediate or occasional medical treatment?* This field is required.

Ex: Diabetes, cancer survivor, pregnant, back issues, therapy

14

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

15

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

16

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

Ex: Hydrochlorothiazide 30 mg

17

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

Yes

No

18

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

19

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

Yes

No

20

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

21

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

22

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

Yes

No

23

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

Yes

No

Other

24

Who was your most recent Vision Insurance Carrier?

25

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

26

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

No

Other

28

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

29

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

30

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

31

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:

• Bring Tax Returns and/or two most recent paystubs if income has not been verified by Healthcare Marketplace / State Administered Healthcare Marketplace

• New job or contract offer letter

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

• Bring Prescriptions and Dosage