Health Coverage questionnaire Legal Name Tobacco useYesNoAddress* Street City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Mailing Address Phone*Date of birth MM slash DD slash YYYY Social Security number Citizenship Status US citizen Permanent Residence Employer name and phone number Total Income (for self-employed, only count income after deductions) PCP P.C.P.Phone#Spouse Legal Name Phone#Tobacco useYesNoSpouse Date of birth MM slash DD slash YYYY Spouse Social Security number Spouse Citizenship Status US citizen Permanent Residence Spouse Employer name and phone number Spouse Total Income (for self-employed, only include income after deductions) Child 1 Legal Name Child 1 Date of Birth MM slash DD slash YYYY Child 1 Gender Male Female Child 1 Social Security number Child 1 Citizenship Status US citizen Permanent Residence Child 1 Income & type, if any Child 2 Legal Name Child 2 Date of Birth MM slash DD slash YYYY Child 2 Gender Male Female Child 2 Social Security number Child 2 Citizenship Status US citizen Permanent Residence Child 2 Income & type, if any Child 3 Legal Name Child 3 Date of Birth MM slash DD slash YYYY Child 3 Gender Male Female Child 3 Social Security number Child 3 Citizenship Status US citizen Permanent Residence Child 3 Income & type, if any Child 4 Legal Name Child 4 Date of Birth MM slash DD slash YYYY Child 4 Gender Male Female Child 4 Social Security number Child 4 Citizenship Status US citizen Permanent Residence Child 4 Income & type, if any Select each person who needs coverage: Yourself Spouse Child 1 Child 2 Child 3 Child 4 Tell us about any recent life changes:Health coverage loss?SelectNoYesGot or will receive unemployment compensation this year?SelectNoYesHousehold size changes: Got married?SelectNoYesHad a baby, or adopted/fostered a child?SelectNoYesGained/became a dependent?SelectNoYesIf yes was answered to any of the above please provide dates of the change. Other: healthcare coverage lost:Got divorced or legally separated and lost health insurance?SelectNoYesCOBRA premium assistance is ending?SelectNoYesIf yes was answered to any of the above please provide dates of the change. Residence or Income changes:Changed your primary place of living?SelectNoYesHad a qualifying change in income?SelectNoYesIf yes was answered to any of the above please provide dates of the change. Other Circumstances:Denied Medicaid or chip?SelectNoYesRecently gained citizenship or lawful presence in the U.S.?SelectNoYesWas released from incarceration?SelectNoYesEmployer offered help with cost of coverage through HRA/QSEHRA?SelectNoYesMember of a federally recognized tribe/Alaskan Native shareholder?SelectNoYesIf yes was answered to any of the above please provide dates of the change. DoctorsPlease list all doctors that you are currently seeing MedicationsPlease list all medications that you are currently using How did you hear about us? Facebook Online Search Event Hospital Referral Physician Referral Friend PhoneThis field is for validation purposes and should be left unchanged.
