Healthcare Marketplace Application

Healthcare Marketplace Application

Application Details

Application Date:   Requested Effective Date:

Applicant Information

Household Members

List all persons who live in your household and who you want included in this application. Provide government ID or last 4 digits of Social Security Number where requested.

Date of Birth:   Relationship:   SSN Last 4:

Date of Birth:   Relationship:   SSN Last 4:

Date of Birth:   Relationship:

Date of Birth:   Relationship:

Income and Employment

Provide estimated monthly or annual income for each household member who receives income. Income will be used to determine eligibility and plan cost.

Applicant Annual Income:   Pay Frequency:

Current Coverage

Do you or any household member currently have health coverage? Yes No

Plan Preferences

Indicate preferred plan characteristics. Selection is not binding; it documents your preferences for enrollment assistance and eligibility calculations.

Preferred Provider Network:

Medical Information (for plan selection)

Authorizations, Attestations, and Certifications

By signing this application I certify, under penalty of perjury and other civil or criminal penalties as provided by law, that the information I have provided on this form is true, complete, and correct to the best of my knowledge. I understand that falsifying information to obtain coverage or subsidies may result in denial of enrollment, termination of coverage, repayment obligations, or prosecution.

I authorize the exchange of information in this application, including verification of income, citizenship or immigration status, and eligibility with employers, financial institutions, government agencies, and other third parties as necessary to determine eligibility and enroll me and my household members in health coverage. I further authorize release of enrollment and claims information for coverage administration, payment, and coordination of care.

I understand that I may withdraw or revoke this authorization at any time by providing written notice, except to the extent that action has already been taken in reliance on this authorization. This authorization expires on the date specified below, or upon separation of the applicant from any program for which the authorization was provided, whichever occurs first.

Privacy Notice / HIPAA Acknowledgment

I acknowledge receipt of the marketplace privacy practices and notice of privacy rights. I understand that my protected health information (PHI) may be used and disclosed to facilitate enrollment, plan administration, and payment. I understand my rights with respect to PHI, including the right to request restrictions and to receive a paper copy of the notice of privacy practices.

I consent to the use and disclosure of my PHI as described above for the purposes of enrollment, premium billing and collection, and coordination of benefits. This consent applies to the applicant and to any listed household members for whom I am authorized to act.

Release for Verification

I authorize any person, employer, organization, or government agency to release any information necessary to determine eligibility for coverage, premium tax credits, or cost-sharing reductions. This includes wage and income information, benefit information, and immigration status. I understand that records obtained may be used only for eligibility determinations and related appeals.

Acknowledgment

I understand that submission of this application is an attestation to the facts as stated herein. I understand that eligibility determinations may require documentation and that coverage is not effective until enrollment is confirmed and any required premiums are paid. I consent to receive communications about eligibility and enrollment via the contact information provided.

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