Good Work Austin Health Access

Good Work Austin Health Access — Intake Form
Full Legal Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number (mobile preferred)*
Please enter a valid phone number.
Email Address*
example@example.com
Preferred Method of Contact*

TextCallEmail
Home Address (must be in Travis County)*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City*
State*
ZIP Code*
Proof of residency upload (upload utility bill, lease, or official mail showing Travis County address)*

Cancelof
Employment Details
Current Employer Name*
Business Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Type of Business (restaurant, bar, café, catering, food truck, hotel, etc.)*
Employer Contact Name (manager/owner)*
Employer Contact Phone/Email*
Your Job Title/Role*
Start Date of Employment*

MonthDayYear
Date
Average Hours Worked Per Week*
How many full-time employees are at your workplace?*
Do you work at multiple food/hospitality jobs?*

YesNo
If yes, please provide details on additional employers including the name of the business and how many full-time employees on staff.
Proof of Employment Upload (recent pay stub, W-2, or employer letter)*

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Household and Income Information
Number of people in your household (include spouse, if applicable)*
Marital status*

SingleMarriedDivorcedWidowedSeparatedDomestic PartnershipOther
Do you plan to include your spouse on coverage?*

YesNo
Total household income (annual or monthly)*
Source(s) of income (employment, self-employment, tips, etc.)*
Proof of income upload (recent pay stubs, prior year tax return, or employer letter)*

Cancelof
Health Insurance Coverage
Do you currently have any health insurance coverage?*

YesNo
If yes → What type?
Have you been enrolled in MAP or MAP Basic in the past year? (https://www.centralhealth.net/map/)*

YesNo
Does your employer currently offer health insurance?*

YesNo
Are you interested in receiving help with Affordable Care Act (ACA) enrollment?*

YesNo
Are you interested in help enrolling in MAP/MAP Basic if not ACA-eligible?*

YesNo
Citizenship Status
Select your Citizenship status*

U.S. citizenLawful permanent resident (green card holder)Refugee/asyleeTPS holderOther lawfully present non-citizen
Demographic Data

Your answers will be used only for reporting and program improvement purposes. They will not be connected to your name or application and will not affect your eligibility in any way.
Race*

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOther
Ethnicity*

Hispanic or LatinoNot Hispanic or LatinoOther
Gender Identity*

MaleFemaleNon-binaryTransgenderPrefer not to sayOther
Should be Empty:

Good Work Austin Health Access — Intake Form

Employment Details

Household and Income Information

Health Insurance Coverage

Citizenship Status

Demographic Data