ACA ACA / Medicare Form Outside Center Phone Number * FirstName * LastName * Age? (How old are you?) * 19-64 years old (ACA) 65-79 years old (Medicare) Older than 79 (too old) Under 19 (too young) Date of Birth * Do you currently have Medicare Parts A & B? * Yes No Are you on Medicaid or do you have Medicare Advantage? * Yes No Are you a US Veteran or do you have Tricare for life? * Yes No Annual Income between $13k max $50k? * Yes No Does NOT Qualify - End Call Does NOT Qualify = Over 65 with VA Benefits - End Call Does NOT Qualify = DQ Income - End Call Does NOT Qualify - Fix Form = Under 65 with Medicare Not Allowed QUALIFIED SEND CALL QUALIFIED SEND CALL Email Address * Address2 City * State * AKALARAZCACOCTDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Zip * If you are human, leave this field blank. Submit
