Sharing Stops SufferingMarketplace Health Insurance Assistance Application Form - All forms are secure, encrypted, and HIPPA compliant. All information entered is encrypted and secure. All questions must be answered. If it is not applicable, please enter NA. If you need further assistance, you may contact Brooke at (631) 512-1567. Thank you. Please enable JavaScript in your browser to complete this form.How Did You Hear About Us? *Name *GenderMaleFemalePrefer not to sayAddressAddress Line/City/State/ZipPhone NumberEmail *Date of BirthMM/DD/YYYYSocial Security NumberApproximately how much do you estimate you will make in profit each month this year?What type of work do you do or do you plan on doing?Do you have a doctor, provider, or specific treatment ,center already that you would like us to make sure is covered by the insurance you choose?Are you single (according to your taxes)?YesNoAre you a US citizen?YesNoDo you have health insurance currently?YesNoIf YES ABOVE, then is it through the marketplace already?YesNoN/AHave you been married, divorced, had a child, released from incarceration or lost a job in the past 60 days?MarriedDivorcedHad a childReleased from incarcerationLost JobN/AWhat is the name of your employer if you have one?Do you dental insurance?YesNoCONSENT OF REPRESENTATION With the guidance of a licensed broker, Sharing Stops Suffering assists those impacted by their mental health issues, whether in crisis or recovery, obtain affordable health insurance in order to get necessary medical treatment and appropriate care. I voluntarily give consent of representation to Sharing Stops Suffering to guide me with the health insurance process through the healthcare exchange/marketplace. I understand all information submitted to Sharing Stops Suffering is protected under the Federal regulations governing Confidentiality and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. pts 160 & 164, and cannot be disclosed without my written consent unless otherwise provided for by the regulations. I also understand that I may revoke this consent at any time, in writing, except to the extent that action has been taken in reliance on it. I understand that by receiving insurance through the healthcare exchange/marketplace, I am using tax credits to offset the cost of the chosen health insurance plan. Should I have tax-related questions I will consult with my tax professional and I will not hold Sharing Stops Suffering liable in any way. Sharing Stops Suffering does offer a specialized tax professional at a very reduced rate. I understand that Sharing Stops Suffering is a 501c3 non-profit organization that provides Integrative Behavioral Health Counseling and Coaching among a variety of other support services for those in the community and no person benefits financially or is compensated at all from this service. Helping and guiding people with marketplace insurance is a 100% community outreach. By typing your name here, you understand the statement above:Submit Share this:TwitterFacebookLike this:Like Loading...
