Native Health Quote

Is anyone in your Household Native American, or eligible to receive services from IHS? * Required

Contact Name * Required

Zip Code * Required

Contact Phone Number * Required

Household Size * Required

Ages of all Household members applying for coverage * Required

Estimated Annual Household Income * Required

Income *before taxes* for W2, Income *after business deductions* for Self-Employed

$

Please select any of the following that apply to your household:

Not currently covered, wanting to shop

Lost Medicaid/Will Lose Medicaid

Currently have employer coverage but wanting to shop

Currently have a Marketplace plan but wanting to shop

I have preferred doctors

I have non-generic prescriptions

Anything else you'd like considered in your quote?

(Ex. Physicians, clinics, hospitals, prescriptions, etc.)

Consent/Privacy Statement

Archer Insurance & Financial Agency, is authorized to collect Personally Identifiable Information (PII) from me and my dependents to help with acquiring health insurance (acting as my agent). For all Marketplaces, including the Federally Facilitated Marketplace (FFM), the definition for PII is information that can be used to distinguish or trace an individual’s identity, alone, or when combined with other personal or identifying information that is linked or linkable to a specific individual. Examples of PII include, but is not limited to, name, social security numbers, dates of birth, addresses, phone numbers, healthcare providers, prescription drugs, and other information used in assisting as an agent in securing my health (and other) insurance through insurance companies and/or within the Federally Facilitated Marketplace (FFM). My PII will only be used to carry out insurance placement and FFM functions on my behalf. The PII requested will be minimal and as necessary to carry out agent (Archer Insurance & Financial Agency) responsibilities and functions. It is my option NOT to allow and use of my PII for insurance and/or Archer Insurance & Financial Agency activities, however limiting, or not allowing, PII to be disclosed MAY prevent me from enrolling in the FFM and/or insurance I am seeking.

The help provided by my agent, Archer Insurance & Financial Agency, is based upon information I provide for myself and/or dependents. Archer Insurance & Financial Agency transmits and stores PII in a secure and encrypted environment per ACA, FFFI Consent to the collections and use of :

1.Collecting or using any consumer personally identifiable information (PII) for the purposes of providing a quote or estimate on Marketplace coverage options.

2.Conducting a person search for consumer eligibility applications using an approved Classic Direct Enrollment (Classic DE) or Enhanced Direct Enrollment (EDE) website.

3.Actively helping a consumer apply for Marketplace coverage or financial assistance by completing an eligibility application on their behalf.

4.Actively enrolling a consumer in a Marketplace qualified health plan (QHP).

5.Making updates to a consumer’s eligibility application throughout the year via an approved Classic DE or EDE website.

6.Checking the status of a consumer’s coverage or their eligibility application, including their eligibility for financial assistance.

I hereby understand that any and all request of Cancellations / Terminations must be submitted in writing with signature, date and Policy number by the Primary holder. I understand I may revoke any part of this authorization at any time upon written request to Archer Insurance & Financial Agency I also understand that I may limit the PII disclosures upon written request to Archer Insurance & Financial Agency. Requests should be mailed to: (address below) Or I can revoke access at any time by contacting CMS/Healthcare.gov

Consumer Printed Name * Required

Consumer Signature * Required

Email * Required