General Enrollment Form

Confidential Enrollment Form

**Every Enrollment MUST have a Photo ID & Selfie
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number as text confirmation may be needed.Format: (000) 000-0000.
Email
*Innacurate social security numbers will not be enrolled
Are you Married
Does Your Spouse Need Coverage?
Do you plan on filing a Tax Return
If you do not plan on filing a tax return, you will not be enrolled
Total People on Tax Return (Including yourself)
Additional Tax Dependants
Are You a US Citizen
Tobacco User
Are you Currently incarcerated (Jailed or Detained)
Are you American Indian or Alaska Native.
Did you receive a subsidy (Advance Premium Tax Credit or APTC) for health insurance through the Marketplace last year, and did you file a federal tax return that year and reconcile your APTC using IRS form 8962?

Eligibility Application Attestation

Licensed Agents: Scott DeGroot NPN:16585155/ Lesa Jacoby NPN: 20077989/ Larry Hamilton NPN: 11384312
I,

First NameLast Name
am filling out this form on the date listed on this form to renew or enroll in health coverage for the 2026 plan year.
Additionally, have reviewed the eligibility application details with my agent and attest to the following:

#1. The details provided in the eligibility application are accurate, and I have provided true answers to all of the questions to the best of my knowledge

#2. I have been provided an explanation of the attestations at the end of the eligibility application

Eligibility Application Attestations

·         If anyone on this application enrolls in Medicaid, I’m giving the Medicaid agency the right to pursue and get any money from other health insurance, legal settlements, or other third parties. I’m also giving the Medicaid agency rights to pursue and get medical support from a spouse or parent.

·         If a child on this application has a parent living outside of the home, I know I’ll be asked to cooperate with the agency that collects medical support from an absent parent. If I think that cooperating to collect medical support will harm me or my children, I can tell the agency and I may not have to cooperate.

·         I know that I must tell the program I’ll be enrolled in if information I listed on this application changes. I know I can make changes in my Marketplace account or by calling the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325), or by calling my agent at 803-851-3589. I know a change in my information could affect eligibility for member(s) of my household.

·         I understand that based on the information I provided, I am receiving a tax subsidy from the government. If I provide false or incorrect information, or if I do not update my information as it changes throughout the plan year, this may affect my tax status, which could result in the loss of some or all of my tax return, and/or the need to pay back some or all of this subsidy.

·         I know that information on this form will be used only to determine eligibility for health coverage, help paying for coverage (if requested), and for lawful purposes of the Marketplace and programs that help pay for coverage.

·         I’m signing this application under penalty of perjury, which means I’ve provided true answers to all of the questions to the best of my knowledge. I know I may be subject to penalties under federal law if I intentionally provide false information.

·         Other: *The attestations may be some or all of the above listed statements and will vary depending on the eligibility determinations of each consumer.
Signature

Enrollment Consent:

I,
Name

First NameLast Name
Give my consent to Scott DeGroot (NPN:16585155) and/or Larry Hamilton (NPN: 11384312) and/or Lesa Jacoby (NPN:20077989) to serve as the health insurance agent or broker for myself, and/or my entire household if applicable, for purposes of enrolling in a Qualified Health Plan (QHP) offered on the Federally facilitated marketplace (FFM). By consenting to this agreement, I authorize the above mentioned agents and affiliates to view and use the confidential information provided by me in writing, electronically, or by phone for the purposes of: searching for a marketplace application, completing an application for eligibility and enrollment in a marketplace qualified health plan or other government insurance affordability programs such as Medicaid, CHIP, or advance tax credits to help pay for marketplace premiums; providing ongoing account maintenance and enrollment assistance, as necessary, re-enrolling; and/or responding to inquiries from the marketplace regarding my application.

I understand that the agent will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The Agent will ensure that my PII is kept private and safe when collecting, storing, and using PII for stated purposes above.

I confirm that the information I provided for entry on my Marketplace eligibility and enrollment application is true and accurate to the best of my knowledge. Furthermore, I confirm that I have reviewed and completed my application and that all information is accurate.

I understand that I do not have to share additional personal information about myself or my health with my agent beyond what is required on the application for eligibility and enrollment purposes. I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by contacting my agent at 803-851-3589 or by emailing ratefinders@gmail.com, or by calling the health marketplace at 800-318-2596.
Signature
Every Enrollment Must have a Photo ID and Selfie

By electronically signing my name, and uploading my ID and Selfie, I acknowledge that I have read, understand, and agree to the enrollment consent & application eligibility attestation.
Take Photo of ID
Take Photo of Yourself holding ID or with Thumbs Up
To see all plans available in your area, use the following link:

https://www.healthsherpa.com/?_agent_id=scott-degroot-woajgg

If you believe your income will change from what you provided on
this form, call us at 803-851-3589 to update your income estimate.

Important: Failure to provide accurate income information could impact your tax status including forfeture of your tax return.
Comments/ Plan selection
Principal Agents: Scott DeGroot NPN: 16585155 / Larry Hamilton NPN: 11384312

Income Certification Acknowledgement

To Whom it May Concern,
My name is:First Name* Last Name* . My date of Birth is DateI certify that I currently work at (name of Company): blanks* I estimate my income to be blank* Monthly. I am providing this letter to the federally facilitated Marketplace to verify my income. I can update my information by calling my agent at 803-851-3589.
Signature
Should be Empty:

Confidential Enrollment Form

Eligibility Application Attestation

Income Certification Acknowledgement