Health Insurance Interest Form

It is our pleasure to assist you in enrolling for individual insurance on The Marketplace (aka Obamacare).

The only requirements to enroll are that you are legally residing in the United States and and that you will be physically present in the country for the majority of the year in which you receive health insurance.

YOU DO NOT NEED TO BE A US PERMANENT RESIDENT OR HAVE A SOCIAL SECURITY NUMBER.

The open enrollment period for 2024 begins on November 1st, 2023 and ends on January 15th, 2024.
In some exceptional circumstances, individuals can enroll for health insurance outside of this period.

All information that you submit below will be transmitted through a secure, encrypted server. Please note that filing out this form is not a commitment to enroll in a health insurance plan. However, we need this information in order to assist you in submitting an application so that you can view your insurance options.

Make your Appointment

Please click on the link below to set up your enrollment appointment with our staff: https://squareup.com/appointments/buyer/widget/5rmplhqxkmpu55/HP5H60G0M7323

You have the option to schedule a video call or meet in person at our Oakland Park office.
If you have an in-person appointment, bring proof of income and immigration status with you.

Create a Healthcare.gov Account

Click on the following link: https://www.healthcare.gov/create-account

Follow the steps below to create your healthcare.gov account

Enter some basic information, like your name, address, and email.
Choose a username and password.
Create and answer security questions for added protection.
Click "Create Account."
Open the e-mail you receive and click "verify my e-mail address."
Log in to healthare.gov using your username and password
Enter more information such as your date of birth and social security number.
If you don't have a social security number, leave that field black. Click submit.
(a) If you were verified, answer four security questions to confirm your identity.
(b) If you were not verified, upload a picture of your passport photo page.
Healthcare.gov will verify you in 1-3 days and send you an e-mail when done.

Client Information

First Name

Last Name

Date of Birth (DD Month YYYY)

Email Address

Cell Phone Number

Home Address

City/Town

Zip Code

Immigration Documents

Do you have a US social security number?

Yes No

What is your social security number?

Do you have an alien identification number?

Yes No

What is your alien identification number?

Are you currently in the process of applying for permanent residency?

Yes No

When did you submit USCIS Form I-485?

Point of Contact

Would you like me to be able to discuss the details of your insurance enrollment with someone else? If "Yes", please list their contact information in the spaces provided below. Completing this section signals your consent for me to discuss your health and/or financial information with the individual whom you have specified.

Yes No

First Name

Last Name

Cell Phone Number

Email Address

Relationship to you

Medical Information

List any medical condition(s) you have and the medication(s) used to treat them

List the name and specialty of any doctors that you see on a regular basis

Are you currently pregnant or trying to conceive?

Yes No N/A

Do you currently use any tobacco products?

Yes No

Financial and Family Information

Most working-class individuals are eligible for government discounts called “subsidies” which in many cases significantly reduce the price of your health insurance policy. To receive subsidies, you must file income taxes at the end of 2024. If you are married, you must be filing a joint tax return with your spouse. You are not allowed to receive any subsidies if your tax filing status will be “married filing separately”.

If eligible, would you like to receive subsidies to reduce the cost of your health insurance?

Yes No

Will you file your income taxes at the end of 2024?

Yes No

If married, will you file a joint tax return for 2024?

I am not married Yes No

How many individuals will be included in your household tax return for 2024?

What do you estimate to be your total household income for 2024?

What type of health insurance coverage does your spouse have?

Individual Employer Medicare Medicaid None

Has your spouse's employer offered to cover you under their insurance plan?

Yes No Unsure

Broker Consent

I hereby permit Joshua Villanueva, a health insurance broker licensed in the State of Florida, and/or any of his proxies to assist me in obtaining a health insurance policy, be it through the health insurance marketplace or directly from a private insurer. Insofar as it is necessary for the achievement of that objective, I expressly permit Joshua Villanueva and/or his proxies to engage in the following actions:

- Conducting an online person search on my behalf

- Assisting me with completing a Marketplace eligibility application

- Assisting me with plan selection and enrollment

- Assisting me with ongoing account/enrollment maintenance

-Obtaining immigration records required for my application

I understand that I will be asked to provide Joshua Villanueva and/or his proxies with personal identifiable information which is required to apply for an insurance policy as well as personal financial information if I request a determination of my eligibility for government assistance. Any information that I provide to this end will be kept confidential and will not be disclosed to any third party, except as required by federal or State law.

I have read, understood and agree to "Broker Consent"

This consent will automatically expire on December 31st, 2024. You may rescind your consent at any time before then by sending an email communicating your request to director@gatewayimmigration.com

Your information will be encrypted.

Health Insurance Interest Form

Make your Appointment

Create a Healthcare.gov Account

Client Information

Immigration Documents

Point of Contact

Medical Information

Financial and Family Information

Broker Consent

Health Insurance Enrollment Assistance