Healthcare Questionnaire

Healthcare Questionnaire

Please fill out this health survey
Application

RenewalNew Application
First and Last Name*

First NameLast Name
Today's Date

MonthDayYear
Date
Referred By
Date of Birth

MonthDayYear
Date
Social Security Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Yearly Adjusted Gross Income (after deductions)
Any additional income?
Employer
Employer's Phone
Please enter a valid phone number.
Adding Spouse

YesNo
Spouse's Full Name

First NameLast Name
Spouse's Date of Birth

MonthDayYear
Date
Spouse's Social Security Number
Spouse's Email
example@example.com
Spouse's Number
Spouse's Employer
Spouse's Employer Number
Adjusted Gross Income (after deductions)
Do you have a child One?

YesNo
Child's One Gender
Child's One Full Name

First NameLast Name
Child's One Social Security Number
Child's One Date of Birth

MonthDayYear
Date
Child's One Income
Does Child One Need Coverage?

YesNo
Do you have a child Two?

YesNo
Child's Two Gender
Child's Two Full Name

First NameLast Name
Child's Two Social Security Number
Child's Two Date of Birth

MonthDayYear
Date
Child's Two Income
Does Child Two Need Coverage?

YesNo
Do you have a child Three?

YesNo
Child's Three Gender
Child's Three Full Name

First NameLast Name
Child's Three Social Security Number
Child's Three Date of Birth

MonthDayYear
Date
Child's Three Income
Does Child Three Need Coverage?

YesNo
Do you have a child Four?

YesNo
Child's Four Gender
Child's Four Full Name

First NameLast Name
Child's Four Social Security Number
Child's Four Date of Birth

MonthDayYear
Date
Child's Four Income
Does Child Four Need Coverage?

YesNo
Name of Doctors

First NameLast Name
Medications that are expensive that you want to be sure are covered.
REASON APPLYING FOR COVERAGE AND/OR LOST COVERAGE DATE:
To complete your eligibility application, please respond to this email confirming the following: 1) Prior to beginning the eligibility application:- you gave Amy Dahl with CIP Group, consent to serve as the health insurance agent for you and your entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace.- you authorized Amy Dahl with CiP Group, to view and use the confidential information provided by you in writing, electronically, or by telephone for the purposes of 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; or -Responding to inquiries from the Marketplace regarding my Marketplace application. -You understood that Amy Dahl with CIP Group will not use or share your personally identifiable information (PII) for any purposes other than those listed above. 2) You understand that your consent remains in effect until you revoke it, and you may revoke or modify your consent at any time by contacting me at the phone number or email address shown below. 3) We have reviewed the information provided for entry on your Marketplace eligibility application and that such information is true and accurate to the best of your knowledge, and I have provided an explanation of the attestations at the end of the eligibility application.By signing below, you confirm to the above statements:

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