Health Insurance NW Intake Form

Health Insurance NW Intake Form

Completing this form does not enroll you in health insurance or guarantee coverage. A licensed Health Insurance NW broker will review your information with you to help determine your eligibility and coverage options. Our services are free for individual and Medicare clients and does not increase your monthly premiums. For group health plans, fees may apply — but only if authorized in writing as part of a formal agreement.
Your Legal Name*
First Name
Middle Initial
Last Name
Nickname
Phone Number*
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Sex (assigned at birth)*

MF
What type of health coverage are you looking for?*

Medicare (for those turning 65, already 65+ or with certain disabilities)Individual (for yourself if under 65)Family (for you and your family if all under 65)Group Plan (for your employees or business)
Terms & Conditions

Please Click to Agree

	Full Name of Prescription Medication	Dosage (eg. 20 mg)	Frequency (eg. 2x per day)	Type of Medication	Is a Generic Version okay?
Prescription 1
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Prescription 20

	Full Name of Prescription Medication	Dosage (eg. 20 mg)	Frequency (eg. 2x per day)	Type of Medication	Is a Generic Version okay?
Prescription 21
Prescription 22
Prescription 23
Prescription 24
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