ACA Qualification Form

Answer the Following Questions Accurately to Authorize Your Application!

First Name *

Last Name *

Email *

Phone *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

Are you currently enrolled in medicare OR medicaid? *

Yes

Just lost coverage

Losing Coverage

If you are currently enrolled in a medicare or medicaid plan you won't qualify.

If you recently lost coverage you can continue the application.

What is the date you are losing medicaid coverage? *

Have you used tobacco 4 or more times a week in the past 6 months? *

Yes

What is your address where we can mail the cards?

Street Address *

City *

State *

Zip code *

Primary Date of Birth MM-DD-YYYY *

Please remember to switch the birth year

Primary Applicant's Social Security Number * *

What is your gender? *

Do you have a Spouse? *

Yes

Spouse Legal First Name * *

Spouse Legal Last Name * *

Spouse's Gender * *

Spouse's Date of Birth MM-DD-YYYY * *

Spouse Social Security Number

What is your employment status? *

Employed

Unemployed

Other

What is your Employer Name? *

What is your Employer phone number? *

Do You Have Any Dependents? *

Yes

Dependent 1 Full Legal Name * *

Dependent 1 Gender * *

Dependent 1 Date of Birth MM-DD-YYYY * *

Dependent 1 Social Security Number

Do You Have a 2nd Dependent? *

Yes

Dependent 2 Full Legal Name * *

Dependent 2 Gender * *

Dependent 2 Date of Birth MM-DD-YYYY * *

Dependent 2 Social Security Number

Do You Have a 3rd Dependent? *

Yes

Dependent 3 Full Legal Name * *

Dependent 3 Gender * *

Dependent 3 Date of Birth *

Dependent 3 Social Security Number

Do You Have a 4th Dependent? *

Yes

Dependent 4 Full Legal Name * *

Dependent 4 Gender * *

Dependent 4 Date of Birth *

Dependent 4 Social Security Number

Do You Have a 5th Dependent? *

Yes

Dependent 5 Full Legal Name * *

Dependent 5 Gender * *

Male

Female

Dependent 5 Date of Birth *

Dependent 5 Social Security Number

1. Consent & Review Consent Form

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.

I, give my permission to Dima Yovko NPN: 20066498 to serve as the health insurance agency 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 telephone only for the purposes of one or more of the following:

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 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 emailing [email protected]

I understand that the Agency 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.

Full Name *

Signature *

Clear

Marketplace Attestation

I understand that I’m not eligible for a premium tax credit if I’m found eligible for other qualifying health coverage, like Medicaid, Children's Health Insurance Program (CHIP), or a job-based health plan. I also understand that if I become eligible for other qualifying health coverage, I must contact the Marketplace to end my Marketplace coverage and premium tax credit. If I don’t, the person who files taxes in my household may need to pay back my premium tax credit. *

Agree

Disagree

The Centers for Medicaid & Medicare Services (CMS) now requires two forms of consent from our clients. You have already completed the first form of consent. Please read the attestations and sign that you understand. Select whether you agree or disagree to adhere to Marketplace regulations. Each year we inform you that you must file your taxes, how eligibility works, and how tax credits are reconciled.

Please note that we cannot enroll you without your consent. Disagreeing with any of the below attestations may hinder the ability to enroll in a plan. Please ask your agent if you need further explanation on any of the following.

I understand that because the premium tax credit will be paid on my behalf to reduce the cost of health coverage for myself and/or my dependents: • I must file a federal income tax return for the 2024 tax year. • If I’m married at the end of 2024 , I must file a joint income tax return with my spouse. I also expect that: • No one else will be able to claim me as a dependent on their 2024 federal income tax return. • I’ll claim a personal exemption deduction on my 2024 federal income tax return for any individual listed on this application as my dependent who is enrolled in coverage through this Marketplace, and whose premium for coverage is paid in whole or in part by advance payments of the premium tax credit. If any of the above changes: • I understand that it may impact my ability to get the premium tax credit. • I also understand that when I file my 2024 federal income tax return, the Internal Revenue Service (IRS) will compare the income on my tax return with the income on my application. I understand that if the income on my tax return is lower than the amount of income on my application, I may be eligible to get an additional premium tax credit amount. On the other hand, if the income on my tax return is higher than the amount of income on my application, I may owe additional federal income tax. *

Agree

Disagree

To make it easier to determine my eligibility for help paying for coverage in future years, I agree to allow the Marketplace to use my income data, including information from tax returns, for the next 5 years. The Marketplace will send me a notice, let me make any changes, and I can opt-out at any time. *

Agree

Disagree

Signature 3 *

Clear

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.

Are you currently enrolled in an ACA Marketplace or Ambetter Plan? *

Yes

Did You Apply For Marketplace/Healthcare.Gov Coverage This Year? *

Yes

I understand that if I am currently enrolled in a health insurance plan through the Marketplace, and this plan is not the most suitable option based on my specific needs, coverage requirements, or eligibility criteria, the agent has my consent to explore and enroll me in alternative health insurance plans offered by other carriers. Additionally, I acknowledge that deductible or out-of-pocket maximums could vary upon submission on the healthcare marketplace. *

I agree

FINAL STEP FROM CLAIMING YOUR

$0/MONTH INSURANCE