2020 Affordable Care Act Information Questionnaire Please enable JavaScript in your browser to complete this form.Name *FirstLastAddress Line 1 *Address Line 2City *State *Zip *Email *Phone *How did you hear about us?/Who may we thank for the referral? *Date of Birth *Gender *# Children that are Tax Dependents: *Household Modified Adjusted Gross Income *Is anyone currently pregnant? *YesNoDoes anyone smoke? *YesNoIs anyone covered under Medicaid? *YesNoIs anyone covered under Medicare *YesNoAny child away at School? *YesNoWho do you currently have Health Insurance with? *No coverage nowEmployer CoverageCOBRA Ambetter AmerihealthAnthem Blue Care Florida Blue Cross South Carolina Blue Cross- Atrium Blue Option FloridaBrighthealth EmblemHealth Fidelis Florida Blue HorizonMolina National GeneralOscar Sunshine AmbetterUnitedIf yes, what date do you lose coverage?If no, when did you last have coverage?Has anyone recently been married or divorced? *YesNoAny recent deaths in your immediate family? *YesNoAny recent births in your immediate family? *YesNoList everyone to be covered, along with their date of birth: *Submit
