Carpenter Collective - ACA Health Insurance Client Intake Form

Privacy and Security Notice

The information you provide on this form may include Personal Identifiable Information (PII) and Protected Health Information (PHI).

Carpenter Collective LLC collects this information solely for insurance, benefits, and financial-planning purposes. All data is transmitted and stored using encrypted systems compliant with HIPAA privacy and security standards and other applicable federal and state privacy laws.

By signing and submitting this form, you authorize Carpenter Collective LLC to use and disclose your information as necessary to process your request, in accordance with our Notice of Privacy Practices. (Click Link to Review)

I understand that this notice explains how Carpenter Collective LLC may use and disclose my Protected Health Information (PHI) and Protected Identity Information, and outlines my rights under federal law.

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

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

YESNO

Email* This field is required.

example@example.com

Confirm Email

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

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

Click next if you need to create an account

Primary Head of Household ZipCode

Check Topics Below You Need Explained

Monthly Insurance Premiums

In-Network

Out-of-Network

Co-Pays

Co-Insurance

Deductibles

Out-of-Pocket Maximums

Advanced Premium Tax Credits (Monthly Subsidy)

Other

If applicable, select Qualifying Life Event for Special Enrollment Period (SEP)* This field is required.Most SEPs allow 60 days from the date of the qualifying event to enroll. PLEASE NOTE: If you do not qualify for a SEP below, you may have to wait for Open Enrolment (Nov. 1 through Jan.15) to enroll in a plan.

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

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

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

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

Will you be eligible for Medicare in the near future?* This field is required.Turning 65 in the two years, End Stage Renal Kidney Failure diagnosis, ASL diagnosis, or receiving SSI for Disability for almost 2 years

Yes

Not Sure

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

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.

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.

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

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

Describe Your Medical Coverage Needs/ Medical PrioritiesCheck All That Apply

I mostly need coverage for preventative care, immunizations, screenings, and annual checkups

I usually visit my primary care doctor often (Sick Visit Coverage)

I usually visit specialist (Not Primary Care Doctor) more than twice a year (Specialist Coverage)

I usually get Blood Work or Diagnostic Exams at least twice a year (Lab Coverage)

I usually get X-Rays at least twice a year (X-Ray Coverage)

I usually get MRIs, CT Scans or etc. at least once a year

I usually speak with a therapist atleast 1 a month (Mental Health Coverage)

I plan on having a surgery or extensive treatment where I go home the say day (Outpatient Care)

I plan on being hospitalized or staying overnight for medical care (Inpatient Care)

I have a condition that usually causes me to visit the Emergency Room at least once a year (Emergency Room Coverage)

I have a condition that usually causes me to visit the Urgent Care at least once a year (Urgent Care Coverage)

I need coverage for pregnancy (Pregnancy Coverage)

I need coverage for Occupational, Physical, and/or Rehabilation Therapy

I prefer a plan with Health and Dental or Health, Dental, and Vision bundles together

I take more than 5 prescriptions, or my prescriptions are very expensive with/without prescription coverage

Other

Choose Preferred Deductible optionsDeductibles are what you pay in medical bills before the health insurance kicks in and helps with the bills.

No Deductible

$1, 000 or less

2, 500 or less

5, 000 or less

10, 000 or less

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

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

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

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

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

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

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

Yes

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

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

Yes

Dental Coverage NeededCheck All That Apply

Just Preventative Care, Xrays, and Semi-Annual Cleanings

Fillings/ Cavities

Simple Extractions

Root Canals

Crowns

Orthodontics

Endodontics

Periodontics (Gum Disease Treatment)

Dentures

Bridges

Implants

Teeth Gaurd

Invisalign

Other

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

* If document was uploaded, Type N/A also

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

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

Yes

Other

Types of Vision Coverage NeededCheck All That Apply

Eye Exams

Retinal Eye Exams (Diabetes, or Etc.)

Frames/Contact Lens Coverage

Prescription Lens Coverage

Specialty Lens Coverage

Lasik Eye Surgery Discounts

Frames Discounts

Lens Coating

Other

Who was your most recent Vision Insurance Carrier?

* If document was uploaded, Type N/A also

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

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

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

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

Any Additional Services Needed:

Gap Hospital Coverage

Cancer Coverage

Life Coverage

Accidental Coverage

Disability Insurance

Long Term Care

Pension/Annuity

Will, Trust, Estate Planning

Tax Consultation and Preparation

Medicare

Other

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

Carpenter Collective - ACA Health Insurance Client Intake Form