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)

First Last

Phone(Required)

Email(Required)

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?

Best Time to Call

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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