2024楊玫保險健保新客戶申請表

Name姓名*

First Name 名Last Name 姓

Phone Number電話*

Phone Number

Email電子郵件*

example@example.com

Address地址*

Street Address

Street Address Line 2

CityState

Zip Code/邮编

主申請人信息 Applicant Information

2023年是否有健保？Do you have health insurance in 2023?*

有/Yes没有/No

主申請人2024個人/家庭報稅單上有其他家庭成員嗎？Any other family members on the applicant's 2024 personal/family tax return report?*

有/Yes沒有/No

* 請填寫家庭成員信息- (請列出家庭報稅表上的全部家庭成員,不需要申请健保的家庭成员也请提供姓名，性别，生日。请向右滑动屏幕填写所有问题). *

Family Members Information (Please include all the family members in your family annual tax report, for those members in tax report but no need health insurance can provide the personal information without visa type), please click the Add a new row beside for adding additional family members.

有家庭成員目前有Medicaid或Peachcare嗎？Does any family member(s) currently have Medicaid or Peachcare?

有/Yes沒有/No

什麼時候被拒絕的？The date be rejected?

日期/Date

*公民或持有綠卡五年以上的19歲以下孩子，如果最近沒有被Medicaid/PeachCare拒絕過，健保中心根據家庭收入狀況，有可能將孩子的申請自動送入GA Medicaid/PeachCare Program.

Children under the age of 19 who are citizen or have held a green card for more than five years, if they have not been rejected by Medicaid/PeachCare recently, the health insurance center may automatically send the child's application to the GA Medicaid/PeachCare Program based on family income level.

請上傳移民文件 Please upload the immigration document ( 绿卡请上传正反两面的照片；公民请上传公民纸或美国护照的照片，美国出生的不需上传; EAD工卡只需正面照片；如有I797等文件也请拍照）

點擊這裡上傳文件 (Click here to Upload Document)

其他內容及說明Additional Comments or Questions

I give my permission to Amy Insurance Group to serve as the health insurance Agent or broker for myself and my entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace. By consenting to this agreement, I authorize the above-mentioned Agent to view and use the confidential information provided by me in writing, electronically, or by phone only for one or more of the following:

• Searching for an existing Marketplace application

• Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace premiums

• Providing ongoing account maintenance and enrollment assistance, as necessary

• 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 my PII for the stated purposes above.

• I confirm that the information I provide for entry on my Marketplace eligibility and enrollment application will be true to the best of my knowledge.

• I confirm that I have reviewed my completed 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.

Name of primary writing Agent: Mei Yang Agent NPN: 7819308 Phone#: 770-986-6998 Email address: applications@amyins.com

请签名：*

*我確認以上我提供的資料全部屬實，我選擇的經紀人無需對我提供的資料負責。I confirm that the information I have provided above is true and correct. The agent I selected is not responsible for the information I provided.

Date*

Date

楊玫保險2024健保新客戶申請表