Individual Health Intake Form
Help text
Please select below:
A
Current Client
B
New Client
How did you hear about us?
Full Name
*
Address
Zip Code
*
Phone #
*
County
*
Date of birth
*
/
/
Email Address
*
Preferred method of communication:
Email
Phone
Spouse Name
Include if in the tax household
Spouse DOB
/
/
List all dependents and ages
Example: (Sara 12 yrs, John 13 yrs)
Current Coverage
What carrier do you have now? Kaiser, Regence, etc.
Date Coverage Ended or Will End
/
/
If unsure just leave blank
Estimated Household income (Annually)
If unsure, just leave blank
Tax filing status
Choose One
Tax filing-Single
Married (jointly)
Head of Household
Life Change-Expected or Current:
Marriage, baby, moving? Any expected changes upcoming or current?
Current Doctors
We look up doctors with each carrier to see if they are in network, most individual plans have restricted networks.
Prescriptions currently taking?
Example: Fluoxetine, 20mg, etc. We use this to look up formularies with each carrier
Interested in Dental or Vision?
Choose One
Yes-Dental
Yes-Vision
Yes-Both Dental and Vision
No
Current Dentist
Any other information to share?
Agent working with:
*
Choose One
Marlena Close
Rachel Lauser
Audra Moore
Grace Trickett
Unsure?
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