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First Name *

Last Name *

Date of birth *

Email *

Phone *

Address *

City *

State *

Postal code *

Just a few more details about you.

What is Your Gender? *

Primary Applicant Social Security Number *

Additional Applicant Information

Employment Status

Employed

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Current Insurance Carrier

Current Insurance Plan

Do you or anyone in your household applying for coverage currently have Medicare, Medicaid, or VA? *

If you have Medicaid, will your Medicaid end soon?

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Who is your primary care provider?

What is your choice of hospital to attend in event of an emergency?

Please list any specialists that oversee your care or you visit on a regular basis?

Please provide all current prescriptions and dosages.

Do you need extra dental coverage? *

Yes, I would like information

No, not at this time

Would you like a quote on burial insurance? *

Yes, I would like information

No, not at this time

I certify that I will be making the minimum income required for the subsidized healthcare based on the chart. *

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I understand that if I am currently enrolled in a health insurance plan through the ACA or Marketplace, and this plan is not the most suitable option based on my specific needs, coverage requirements, or eligibility criteria, the agent has my consent to explore and enroll me in alternative health insurance plans offered by other carriers.

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National Producer Number for Jeremy Patterson: 8827726

Jeremy Patterson and Medicare Health Connections is NOT AFFILIATED with and Government Agency.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-Medicare or your local state health insurance program, (SHIP) to get more information on your options.

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