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Full-Spectrum Care
Your First Visit
HIV Primary Care
Transgender Primary Care
Dental Care
Pharmacy
Behavioral Health
Case Management
Telehealth & Telepsychiatry
Prevention Services
HIV/STI Testing & Treatment
PrEP (Pre-Exposure Prophylaxis)
Free Condoms – Nice Package
Additional Services
MPV (Mpox)
COVID-19
Clinical Research
Dermatology
Empowerment Connection
Free World Bound
Payment & Insurance
Payment
Your Cost
Insurance
Accepted Insurance Plans
Health Insurance Enrollment
Insurance and Financial Assistance
Resources
Resources & Education
HIV Basics
HIV Stigma
Empowerment Connection
Beneath the Briefs Podcast
FAQs
Find Community Resources
Ways to Help
Give a Gift
Donate Now
Ways to Give
Get Involved
Policy & Advocacy
LifeWalk
Events
Volunteer
About
Who We Are
About PHNTX
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Contact Us
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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
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Last
Phone
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Email
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Zip Code
County
Annual Household Income
This information is used to determine if you are eligible for a federal subsidy.
Family Member Ages
This information is used to determine if you are eligible for a federal subsidy.
Does Your Employer Offer Insurance?
No
Yes
I don't know
Best Time to Call
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:
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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.
I agree
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