Self Enrollment | Prince Health Group

Free Self-Enrollment

First Name *

Last Name *

Date of birth (DOB) *

Gender *

Phone *

Email *

Address *

City *

State *

Zip *

Marital status *

SSN / Tax ID *

We require your SSN to comply with legal requirements and secure your personalized healthcare plan. Your data is safely protected.

Citizenship *

Upload a government-issued ID to verify your identity *

Income

Occupation *

Additional Information

Have you had a change in income or loss of job recently? Y/N

Yes

Have you recently lost health coverage? Y/N

Yes

Have you been denied Medicaid? Y/N

Yes

Will you make $20,000 or less this year? Y/N

Yes

Did you recently have a change of income? Y/N

Yes

Have you recently been married? Y/N

Yes

Have you recently had a child, adopted a child, or placed a child in foster care? Y/N

Yes

Have you recently moved to a new zip code or county? Y/N

Yes

Have you recently been divorced or legally separated? Y/N

Yes

Did you lose medicare? Y/N

Yes

The Marketplace will notify me about updates, allow me to make changes, and offer the option to opt out at any time. *

Agree

Disagree

To find out if I can get help paying for health coverage for the next 5 years, I agree to let the Marketplace use my income details, including tax return information.

I understand that a change in my information might alter the eligibility for member(s) of my household. *

Agree

Disagree

I know I need to tell the program if my information changes. I can do this in my Marketplace account or by calling (xxx) xxx-xxxx

Dependent Information

Do you have any dependents? *

Yes

If you have dependents, please enter their details below. After listing all dependents, scroll down to the next section to finish your enrollment. Thank you!

Dependent #1

Dependent #1 - Full Name

Dependent #1 - Gender

Dependent #1 - Date of birth (DOB)

Dependent #1 - SSN / Tax ID

We require your SSN to comply with legal requirements and secure your personalized healthcare plan. Your data is safely protected.

Dependent #1 - Relationship to applicant

Dependent #2

Dependent #2 - Full Name

Dependent #2 - Date of birth (DOB)

Dependent #2 - SSN / Tax ID

We require your SSN to comply with legal requirements and secure your personalized healthcare plan. Your data is safely protected.

Dependent #2 - Relationship to applicant

Dependent #3

Dependent #3 - Full Name

Dependent #3 - Date of birth (DOB)

Dependent #3 - SSN / Tax ID

We require your SSN to comply with legal requirements and secure your personalized healthcare plan. Your data is safely protected.

Dependent #3 - Relationship to applicant

Dependent #4

Dependent #4 - Full Name

Dependent #4 - Date of birth (DOB)

Dependent #4 - SSN / Tax ID

We require your SSN to comply with legal requirements and secure your personalized healthcare plan. Your data is safely protected.

Dependent #4 - Relationship to applicant

Additional Notes and Signature

Before you complete your self-enrollment, if you have any extra details to add or if you have more than 4 dependents, please specify in the notes section. Lastly, please sign at the bottom to finalize your enrollment. Thank you for choosing us for your healthcare needs!

Notes

Signature (Required) *

Clear

By clicking "Enroll Now" and submitting this form, I confirm that I am at least 18 years old and accept the Privacy Policy and Terms and Conditions.

By pressing the "Enroll Now" button and submitting this form, I give my consent to receive marketing messages from Prince Health Group, through various channels including but not limited to automated calls, emails, and text messages, even if I'm on a Do Not Call / Email list. I understand that message frequency may vary and is a sincere effort to contact me about my insurance inquiry. Standard message and data rates may apply. I can text HELP for assistance or STOP to unsubscribe at any time. Giving this consent is not a requirement for purchase and I can withdraw it at any time.