ACA Review Form

1
Policyholder NameFull legal name as found on your existing policy
First Name
Last Name
2
Have Any Of The Following Changed Since Your Last Enrollment?* This field is required.If yes, please specify on next page.
Address
Contact Information (such as phone number or email)
Marital Status
None of the Above
3
If You Answered Yes to Any of the Options On The Last Page, Please Specify BelowChange of address, contact information, and/ or marital status. If you answered "None of the Above", please put N/A.
Huge
Large
Normal
Small
Ok
Ok
4
Preferred Providers* This field is required.List any/all physicians or specialists that are important for you to continue seeing. For each provider, list their full name, their specialty, and the office location that you visit. Include any preferred hospital system as well. Example: "Dr. John Doe-Primary Care- Canton" and/or "Northside Cherokee"
Huge
Large
Normal
Small
Ok
Ok
5
Prescription Medications* This field is required.Please list the medications that you currently take. Include: Medication name, dosage, and how often you take it Example: "Valsartan, 40mg twice daily"
Huge
Large
Normal
Small
Ok
Ok
6
Household Income* This field is required.Please estimate your modified adjusted gross total household income that you expect to receive during the upcoming coverage year. This helps determine eligibility for financial assistance.
7
Income Source* This field is required.Example: Job, self-employment, dividends etc. Please list every source along with the amount of income they provide.
Huge
Large
Normal
Small
Ok
Ok
8
Number of People in Tax HouseholdHow many people do you expect to include on your federal tax return for the coverage year? Please list the name and birthdate of every member in your household even if they are not seeking coverage- this will ensure more accurate quoting.
Huge
Large
Normal
Small
Ok
Ok
9
What Is Your Biggest Priority This Year?* This field is required.Please Note: I will consider your preferences when reviewing plans, but I cannot guarantee that every priority can be met. Plan availability, provider networks, prescription coverage, and costs vary by insurance company.
Lower monthly premium
Lower deductible
Keep my doctors
Better RX coverage
HSA Plan
Not sure/None of the Above
10
Additional CommentsIs there anything else you'd like me to know before we review your options?
Huge
Large
Normal
Small
Ok
Ok
Should be Empty: