Health Insurance Questionnaire

*Skip any questions that do not apply to you.

Part 1: General Information

Part 2: Your Information

  • Single
  • Married
  • Separated
  • Divorced
  • Other
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Part 3: Family Information

*Skip any questions that do not apply to you.

Dependents:

If you have more than 4 dependents, you can add their info to the "Additional Information" section at the end of this questionnaire.

Part 4: Doctors & Prescription Medications

If you would like me to check network status and Rx coverage, please list any doctors/medical providers you currently see, as well as any prescription drugs you take. This information will be used to make sure these are covered by any plan we choose.

Part 5: Employment & Financial Information

This information will be used to determine Advanced Premium Tax Credit (aka "subsidy") eligibility.

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Part 6: ACA Agent Consent Form

*Based on new regulations that were signed in 2023 by the Center for Medicare Services (CMS), licensed agents and brokers must document express consent from their clients before accessing any personal information or assisting with their renewal. By signing this consent, you are allowing us to help manage and enroll you in health insurance.

Disclosure & Consent Agreement

I hereby authorize Bethany Boos Insurance, LLC (Bethany Boos, Principal Agent; NPN 20111896) to serve as the health insurance agent or broker for myself and my entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace.

 

By consenting to this agreement, I authorize the above-mentioned Agency/ Agent to view and use the confidential information provided by me in writing, electronically, live or by telephone only for the purposes of one or more of the following:

  1. Searching for an existing Marketplace application;

  2. Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace premiums;

  3. Providing ongoing account maintenance and enrollment assistance, as necessary; or

  4. Responding to inquiries from the Marketplace regarding my Marketplace application.

I understand that the Agent will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The Agent will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above.

 

I confirm that the information I provide for entry on my Marketplace eligibility and enrollment application will be true to the best of my knowledge.

 

I understand that I do not have to share additional personal information about myself or my health with my Agent beyond what is required on the application for eligibility and enrollment purposes.

 

I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by reaching out to Bethany Boos at 864-332-9070.

Name of Primary Writing Agent: Bethany Boos

Agent National Producer Number: 20111896

Agent Phone Number: (864) 332-9070

Agent Email: [email protected]

By providing your name and contact information you are consenting to receive calls, text messages, and/or emails from a licensed insurance agent about Health Insurance Plans at the number provided. You are not required to agree in order to purchase products or services and can opt out at any time replying STOP or clicking the unsubscribe link (where available). Msg & data rates may apply.

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