BCI Health

Agent ID
What state is this application for?

Enrollment Data
Name
Date of Birth

MonthDayYear
Sex
SSN
Are you a US Citizen?
Were you born in the US?
What is your USCIS Number?
Address
Email
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Contact Preferences
Marital Status

Employment Data
Income Type
Employer Name
Description of Work
Annual Income
Employer Phone Number
Format: (000) 000-0000.

Spousal Data
Spouse Name
Date of Birth

MonthDayYear
SSN
Income Type
Employer Name
Description of Work
Annual Income
Employer Phone Number
Format: (000) 000-0000.

Dependents
Number of Dependents
Dependent 1
Date of Birth

MonthDayYear
Sex
SSN
Dependent 2
Date of Birth

MonthDayYear
Sex
SSN
Dependent 3
Date of Birth

MonthDayYear
Sex
SSN
Dependent 4
Date of Birth

MonthDayYear
Sex
SSN
Dependent 5
Date of Birth

MonthDayYear
Sex
SSN

Additional Files
Upload Form of Identification

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Upload Consent

Make sure the photo is taken close enough to clearly show the consent form and the customer's face. The form should be readable and must clearly indicate the customer's income bracket, serving as proof of their income level.
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Application Notes

Acknowledgments - Patient Protection & Affordable Care Act (PPACA) Assistance

I (Customer) acknowledge that I have engaged the assistance of an independent Health Insurance Agent (Agent) licensed by the proper authorities, certified by the Centers for Medicare & Medicaid Services (CMS), to assist me in the enrollment process for the Affordable Care Act (ACA) through the Healthcare.gov (Marketplace) website.

In doing so, I understand and agree that all information supplied by me is accurate to the best of my knowledge. If proof of income or any other information is required by the Marketplace, it is my sole responsibility to provide it. I understand that any changes including but not limited to my information, income, health plan, etc. made by me can affect the eligibility/status of my health insurance plan. I also understand that I should be reporting my accurate income estimate, not the estimate that maximizes the amount of premium tax credit for which I may be eligible when completing or updating an application for eligibility.

I understand that my current income and/or premium-cost limitations may result in a lower-level plan with fewer benefits. I understand that my Agent can contact me via text or email which I provided.

By signing this Acknowledgement, I provide my signature, expressly authorizing BCI Health Insurance Agency, their agents, or partner companies to contact me at the number and address provided with insurance quotes or to obtain additional information for such purpose, via live/prerecorded/auto-dialed calls, text messages and/or emails for up to 5 years. I understand that my signature is not a condition of purchasing any property, goods, or services and that I may revoke my consent at any time. I also understand that I can contact my Agent for any questions or any changes I would like to discuss. I consent to my Agent calling the Marketplace Call Center to ask about the status of a Marketplace enrollment as needed, up to once a year. If I need help or have questions about my policy, I understand that I can contact BCI Health Insurance Agency, and/or the Marketplace with the contact information below:

BCI Health Insurance Agency

Phone: (727) 353-3327

Marketplace

Phone: (800) 318-2596

I understand that my policy is discounted through the Affordable Care Act and may or may not contain dental coverage and that if I am unsure of what coverages are contained within my policy, I can read through my policy documents once they are mailed to me and/or reach out to BCI Health Insurance Agency, using the contact information above.

The Customer acknowledges receipt of HIPPA Privacy Information at the time of enrollment and agrees to allow Agent access to Healthcare.gov as needed to secure and maintain health insurance policy throughout the initial term of the plan and subsequent renewals.
Permission To Review

I am voluntarily authorizing and giving consent to (Agent), as a Licensed Health Insurance Agent, to review my health insurance enrollment now and annually, and advise me using all reasonable efforts, that I have made a sound choice for the current policy term and any subsequent policy terms. I understand the main roles of my agent are to advise me on how I can become eligible for certain plans on the Marketplace, build an understanding of my needs as a client, answer any questions I may have about my plan, and assist me in securing coverage.

I understand that my Agent has permission to search for the consumer application using approved Classic Direct Enrollment/Enhanced Direct Enrollment websites in the Marketplace, assist with completing an eligibility application, assist with plan selection and enrollment, and assist with ongoing account/enrollment maintenance.

I understand that this consent will last indefinitely unless I as the client revoke it. I understand that my legal name matches my signature below and I know my agent's name. My signature below also confirms my understanding of all the above.

I give my consent so you can assist me in obtaining marketplace coverage, this includes my consent for you to search the marketplace for applications, get me quotes, apply for a subsidy, and apply for a current application.

In addition, if your plan is changed or altered in any way not authorized between you and the agent below, you authorize said agent to immediately move you back to the plan you originally selected.

Agent Name:

NPN:
Print Name
Signature
Should be Empty: