2020 Affordable Care Act Information Questionnaire Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Phone *Address Line 1 *Address Line 2City *State *Zip *# 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? *YesNoDo you currently have insurance? *YesNoIf 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? *YesNoHow did you hear about us?/Who may we thank for the referral?List everyone to be covered, along with their date of birth: *Submit
