New Health Insurance Client Intake Form Fill out this form ahead of time to make your appointment as smooth as possible Your Personal & Family InformationName(Required) First Middle Initial Last Date of Birth(Required) MM slash DD slash YYYY Tobacco User?(Required)NoYesVeteran?NoYesOther Household MembersNameDate of BirthRelationship to YouTobacco User? (Y/N)Veteran? (Y/N) Add RemoveUse the + button on the right to add more lines.Cell Phone(Required)Email Address(Required) Home Address(Required) Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code CountyCounty Your Insurance & Financial InformationEstimated Household Income (2024 calendar year)Current Insurance CoverageEmployer-provided health planCOBRAOther ACA Marketplace planNo coverageOtherYour Medical InformationDoctors and Other ProvidersProvider NameSpecialtyClinic Name Add RemoveStart with your Primary Care Provider and list as many others (dentist, specialists, etc.) as necessary. Use the + button on the right to add more lines.Prescription MedicationsRx Name (e.g. simvastatin)Dosage (e.g. 10mg)Quantity (e.g. 30)Frequency (e.g. every month) Add RemoveUse the + button on the right to add more lines.Prescription Medications I don't take any prescription drugs NotesAgent InformationAgent(Required)John Ulness NPN: 6530356Marit Ulness NPN: 15887658Erik Ulness NPN: 15952162Don Bachaus NPN: 6493416James Boland NPN: 20305616Who are you meeting with?Are You a Robot?CommentsThis field is for validation purposes and should be left unchanged.
