ACA Appointment Request for Plan Year 2022
In community partnership with Absolute Care, CommunityScape is again providing assistance with enrollment through
Please fill out the following information to request an appointment to explore your insurance options via
. One of our associates will reach out to you to set an appointment to discuss your insurance options. Note that email is our preferred method of communication.
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to save your progress.
What is your first name (what people call you regularly)?
What is your telephone number?
What Georgia County do you reside in?
If you answered "Another County" above, please specify which Georgia County you reside in.
May we leave a message such as "Hello, this is Darie calling to set a health insurance appointment, please call me back?" We follow strict privacy standards, and will not say anything in a message that violates HIPAA.
What appointment format do you prefer?
What organization or which person referred you to our services?
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This form was created inside of Darie L.K. Wolfson.