Health Insurance Application Assistance Form

Yes, I would like a certified PHNTX enrollment navigator to contact me with information about the free health insurance marketplace application assistance.
Name(Required)
This information is used to determine if you are eligible for a federal subsidy.
This information is used to determine if you are eligible for a federal subsidy.
Best Time to Call
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PII Consent(Required)
I allow Prism Health North Texas, including the individual Navigators who are a part of this Navigator organization, to create, collect, disclose, access, maintain, store, and/or use my PII in order to carry out the roles and responsibilities of a Navigator that are authorized by federal statute and regulation and generally summarized in Attachment A, unless I have limited that consent as set forth in this document. I understand that Prism Health North Texas might need to create, collect, disclose, access, maintain, store, and/or use some of my PII in order to provide this assistance.