Health Questionnaire
In order to build the very best plan for you and your needs, please answer the following questions honestly and completely. Please follow the examples if provided. I will never share or sell your information and you can find our privacy policy here. If you have any questions, please let me know.

My service is always completely free to you and you are under no obligation to purchase a plan from me. But if you do, you will only have to pay your premiums and any applicable application fees for your plan. 
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Email *
Address including zip code *
Phone number *
Please provide the FULL legal name and date of birth of EACH person you want to include on your plan. (Ex. Mary Jane Doe 01/01/1911) *
Please provide the height and weight of any adults listed above. (Ex. Mary-5'5, 145 lbs) *
To determine if you qualify for subsidies, please provide your CURRENT a.) annual household income, b.) your most recent filing status, and c.) your taxable household size. (Ex. $30,000, Single, 1)

Please be mindful that any amount of subsidies that you receive that you are not eligible for would reduce your refund or increase the amount of tax you owe. Likewise, if you are entitled to more subsidies than you receive, the difference will either increase your refund or lower the amount of tax you owe.
How much can you comfortably afford to pay each month for your health insurance coverage? 

This is YOUR plan to meet YOUR needs so YOU need to be comfortable. Give me the number that works for YOU. This will provide the budget guideline as I build YOUR plan. No pressure!
What type of health insurance coverage options do you want to explore? Please check all that apply. *
Did the adult applicants have major medical healthcare coverage for at least nine (9) of the last twelve (12) months? *
If the adults had major medical healthcare coverage, what type of coverage did they have? *
How many doctor visits a year do you usually have?

If you go more than 5 times a year, you can pay a little bit more monthly and have your copays built into your plan. If you never go, but want to be financially protected in case of accident/injury/critical illness/surgery/hospitalization; you can look into catastrophic coverage only. 
Would you need maternity coverage in the next 12 months? *
Would you need annual wellness exams or other preventive care? *
Do you need in-person mental health or substance abuse visits? *
Would you need dental/vision/hearing coverage? *
Would you need to see a specialist?  *
Would you need access to telehealth services?  *
Any tobacco use in the past 12 months by any adult listed above? *
If yes to tobacco use, please indicate which adult(s) or child(ren) below.  
If you're trying to quit, when is the LAST time you've used tobacco products? 
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If you plan to apply for a PRIVATE HEALTH INSURANCE PLAN, please list a.) any health conditions, b.) year of diagnosis, and c.) the recommended course of treatment for all applicants IN THE PAST FIVE YEARS. If none, please respond "N/A". (Ex. Mary- Type 2 Diabetes-2019, pills, diet, exercise).


Be mindful! The carrier may not require a medical exam but they will check the medical information bureau (MIB) and run a prescription history check. 
Please list the a.) names, b.) dosage, and c.) first fill date of any prescription drugs currently taken by any applicant IN THE PAST FIVE YEARS. If none, please reply "N/A". (Ex. Mary-metformin, 500 mg, 2x day, 2019)

Be mindful! The carrier may not require a medical exam but they will check the medical information bureau (MIB) and run a prescription history check. 
Please list the name, city & state, and phone number of any providers that you would like to keep. This will allow me to ensure that they are IN-Network with your plan. 

Out of network providers cost more for covered services or are NOT covered at all.
Would you need to have a healthcare plan that could be used nationwide (outside of your resident state)?  *
Desired start date for coverage? Please note that coverage will begin after your application is approved AND when your first premium is paid. *
Any questions or concerns you would like me to address? Please include any issues you currently have or have had in the past with your coverage or plans. (Ex. Services or medications not covered. Limited number of providers. Etc. ) *
Once I build a plan for you, what is the best day and time to reach out to you to go over your options? *
Would you need life insurance? *
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