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

Email

Address *

Address2

City *

State *

Zip *

If you are human, leave this field blank.