ACA Intake Form

1. Client Demographics & Identification

Full Legal Name *Primary Phone *Email AddressSocial Security # (SSN) *Address *County of Residence

Do you currently work?

Yes No

Can you get health insurance through work?

Yes No

Prior Marketplace user?

Yes No

Referral Source

Do you have a spouse?

Yes No

2. Tax Household & Income

Will you file taxes for this year?

Yes No

Expected Tax Filing StatusExpected Dependents ClaimedExpected Total Tax Household

Enter income for everyone in the tax household

Who?Annual Household IncomeIncome Source

3. Applicants Information

Applicant Full NameRelationship to PrimaryDate of Birth (DOB)GenderTobacco UseWill this person have any other health insurance?

4. Doctors & Specialists List

Doctor / Provider NameSpecialty / RoleClinic / Practice NameCity, State

5. Prescription Medications (Rx) List

Prescription Drug NameDosage / StrengthHow many times a day?Preferred PharmacyRx Form

6. Preferred Time To Contact You

When is the best time for us to reach you?

Morning (8:00 AM – 11:00 AM) Afternoon (11:00 AM – 3:00 PM) Evening (3:00 PM – 6:00 PM)

Preferred method of contact

Phone Call Text Message Email

Case Notes & Client Goals

By submitting this form, I give ALC Insure permission to contact me by phone call, text message, or email regarding ACA insurance plans, coverage options, enrollment assistance, and related services. Consent is not a condition of enrollment or the purchase of insurance. Message and data rates may apply. I may withdraw my consent at any time.