ACA Subsidy Application Review
Verification of subsidy application information
Important
This form must be filled out each time any change is made to a Subsidy Application. There are no exceptions.
Client or authorized representative:
Name
*
First Name
Last Name
Client or authorized representative email:
*
example@example.com
Date of birth:
*
-
Month
-
Day
Year
Date
Date of the review:
*
Marketplace Application ID #
*
Assisting agent:
*
Please Select
Gerard Denys
Kris Hardy
Kim Lawler
Karen Midland
Sheena Joyce
Joan Cox
Danielle Giamo
Brenda George
Dan Lyonnais
Brett Harper
John Tracy
Chase Johnson
Cori Kish
Lorraine Hayes
Nancy Smith
Amy Devor
Brooke Miller
Mercedes Perez
Jeffrey Kahler
Varsha Narotam
Lorrie Blandy
Aaron Denys
Jason Jackson
Tina Wellman
Maghan Magruder
Jason Miller
Talena Thompson
Deirdre Murphy
Megan Freeland
Beth McQuillen
Chris Norman
Jessica Zackery
Reeva Pierre
Carl Mastropolo
Kalishia Key
Christina Moriarty
Denise Bloodsworth
Leeshel Gaines
If anyone on your application is enrolled in Marketplace coverage and is later found to have other qualifying health coverage (like Medicare, Medicaid, or the Children's Health Insurance Program (CHIP)), the Marketplace will automatically end their Marketplace plan coverage. This will help make sure that anyone who’s found to have other qualifying coverage won’t stay enrolled in Marketplace coverage and have to pay full cost.
*
Yes
No
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). I can also call my agent to help me. I know a change in my information could affect eligibility, subsidy amounts and premiums for member(s) of my household.
*
Yes
No
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. I agree that the income information on the application is correct, provided by me and that I have reviewed it with my agent.
*
Yes
No
Signature
*
Submit
Should be Empty: