My Care Act

First Name *

Last Name *

Male or Female *

Male

Female

Date of birth *

Physical Address *

State *

City *

Postal code *

Phone *

Email *

Social Security Number *

Do you currently have Medicaid or Medicare?

Yes ( If yes you will not qualify for marketplace)

Will this Coverage be used to go to Rehab in California? *

Yes

Do you have a Marketplace / Obamacare plan? *

Yes

If yes what tribe are you a member of?

Upload your Tribal Card or any documents to verify your American Indian or Alaskan Native Status below: DO NOT UPLOAD DRIVERS LICENSE

Acceptable document types are images (jpg, gif, png, etc.) and PDFs.

The accepted documents include a Tribal Enrollment/Membership card from a federally recognized tribe, a document issued by the Bureau of Indian Affairs (BIA) recognizing you as American Indian/Alaska Native, an authentic document from a federally recognized tribe declaring your membership, a Certificate of Degree of Indian Blood, a Certificate of Indian status card, an I-872 American Indian Card, a document issued by the Indian Health Service (IHS) showing that you were/are eligible for IHS services as an American Indian/Alaska Native, U.S. American Indian/Alaska Native tribal enrollment or shareholder documentation, and a letter from the Marketplace granting a tribal exemption based on tribal membership or Alaska Native shareholder status.

Are you currently enrolled in a Indian Health Service, a tribal health program, or urban Indian health program?

Yes (If yes you can not qualify for this coverage)

Your Employment Information *

Employed

Unemployed

Receiving Social Security

Do you intend to have income this year? *

Yes

No ( if you do not have or intend to have income you do not qualify)

If yes, please provide details: *

Total Expected Annual Income for this year : *

Your Employer Name *

Estimated Monthly Income *

Marital Status *

Single

Married

Divorced

Widowed

Will you file taxes jointly with your spouse this year? *

Yes

Spouse's Name *

Spouse's Birthdate *

Spouse Gender

Male

Female

Do you want your spouse covered on this policy? *

Yes

Spouses Social Security Number *

Spouse's Employment *

Employed

Self-Employed

Social Security Benefits

Unemployed

Spouse's Employer Name *

Spouse's Estimated Monthly Income Before Taxes *

Has your spouse used tobacco 4 or more times a week for the past 6 months?

Yes

Will you claim any dependents on your taxes this year? *

Yes

Dependents Full Name *

Dependents Birthdate *

Male or Female

SOCIAL ONLY NEEDED IF YOU WANT THEM ON THE POLICY

Dependents Social Security Number

Do you have more than one dependent?

Yes

2nd Childs Full Name *

Male / Female?

Male

Female

2nd Childs Date of Birth *

SOCIAL ONLY NEEDED IF YOU WANT THEM ON THE POLICY

2nd Childs Social Security #

Do you claim more than 2 Dependents on your taxes?

Yes

3rd Childs Full Name *

Male? Female?

Male

Female

3rd Childs Date of Birth *

SOCIAL ONLY NEEDED IF YOU WANT THEM ON THE POLICY

3rd Child Social Security #

Do you claim more than 3 Dependents on your taxes?

Yes

NAMES & BIRTHDATES ARE REQUIRED
SOCIAL SECURITY # IS REQUIRED ONLY IF THEY NEED COVERAGE

Please any additional dependents info below.

Do you have a Primary Care Doctor?

Yes

Doctors Full Name ( PCP)

Doctors City

In Order to get a Cost Sharing Reduction and an Advanced Premium Tax Credit you will need to file a tax return for the upcoming year. Will you file a tax return for the coming year? *

Yes

No ( IF YOU CLICK NO YOU WILL BE AUTOMATICALLY DISQUALIFIED)

How did you hear about us? Who Referred you? *

TIKTOK , FACEBOOK , GOOGLE ...?

I understand that providing false information may lead to penalties and loss of coverage. I attest that the information provided is accurate to the best of my knowledge.

Yes

No (IF YOU CLICK NO YOU WILL BE AUTOMATICALLY DISQUALIFIED)

Marketplace Coverage Agreement and Authorization

By signing this agreement, I confirm that the information provided in my Marketplace coverage application is true and complete to the best of my knowledge. I understand that this information will be used to determine my eligibility for health coverage and financial assistance through the Marketplace.

Consent for Use of Income Data:

I agree to allow the Marketplace to use my income data, including information from my tax returns, for the next five (5) years to determine my eligibility for assistance in future years. The Marketplace will notify me if any updates or changes are needed, and I retain the right to opt out at any time.

Eligibility for Premium Tax Credit:

I acknowledge that I am not eligible for a premium tax credit if I am found eligible for other qualifying health coverage, such as Medicaid, the Children’s Health Insurance Program (CHIP), or a job-based health plan. Should I become eligible for any other qualifying health coverage, I understand that I must contact the Marketplace to end my Marketplace coverage and premium tax credit. I also understand that if I fail to do so, the taxpayer in my household may be required to repay the premium tax credit.

Obligation to File Federal Income Taxes:

As a recipient of the premium tax credit, I acknowledge that:

I must file a federal income tax return for the current tax year.
If I am married at the end of the current tax year, I must file a joint tax return with my spouse.
No one else can claim me as a dependent on their federal income tax return for the current tax year.
I will claim a personal exemption deduction on my federal income tax return for the current tax year for any individual listed as my dependent who is enrolled in Marketplace coverage and whose premiums are paid, in whole or in part, by advance payments of the premium tax credit.

Impact of Changes to Information:

I understand that any changes to the information I have provided may affect my eligibility for the premium tax credit. If my actual income reported on my tax return differs from the amount on my application, I may be eligible for additional premium tax credits or, conversely, owe additional taxes.

Requirement to Report Changes:

I agree to report any changes to the information listed in this application within 30 days by updating my Marketplace account or by calling the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325). I understand that such changes may affect the eligibility of members of my household.

Consent to Terminate Coverage:

I authorize the Marketplace to terminate coverage for anyone on my application who is enrolled in both Marketplace and Medicare coverage.

Authorization for Agent Representation:

By providing my signature below, I authorize Sean Brooks (NPN: 18947409) (hereinafter referred to as "Agent") to act as my health insurance agent or broker for myself and my household, if applicable, for enrolling in a Qualified Health Plan (QHP) on the Federally Facilitated Marketplace (FFM). I consent to the Agent accessing and using my confidential information, provided by me in writing, electronically, or by phone, for the following purposes:

Searching for an existing Marketplace application.
Completing an application for eligibility and enrollment in a Marketplace QHP 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.
Responding to inquiries from the Marketplace regarding my application.

I understand that the Agent will not use or share my personally identifiable information (PII) for any purposes other than those listed above and will ensure that my PII is kept private and secure.

Duration of Consent:

This consent remains in effect until I revoke it. I may revoke or modify my consent at any time by contacting my Agent. This agreement replaces any prior authorizations and any currently designated Producers/Agents of record on my policies.

Privacy Notice:

The information contained in this document is confidential and intended solely for the use of the individual or entity to whom it is addressed. This document may contain privileged or legally protected material. If you are not the intended recipient or responsible for delivering it to the intended recipient:

Any use, dissemination, forwarding, or copying of this document is STRICTLY PROHIBITED.
Please immediately notify the sender by phone and destroy the document.

Please click agree or disagree *

Agree

Disagree (IF YOU CLICK DISAGREE YOU WILL BE AUTOMATICALLY DISQUALIFIED)

Signature *

Clear

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