Marketplace Review of Eligibility Application

Step 1 of 4

Name*
First Last
DOB*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State ZIP Code
County*
Email*
Phone*
Phone Type*
- Home
- Work
- Cell
Estimated Adjusted Gross Household Income for 2024?*
How will you file your taxes in 2024?*
- Single
- Married
- Married Filing Single
How many dependents will you claim on your taxes for 2024?*
Do you have any dependents that need removed from your plan January 1, 2024?
If yes, please list the name(s) of dependents to be removed:
Use the + icon at the end of each row to add additional rows as needed
First Name Last Name Date of Birth

Use the + icon at the end of each row to add additional rows as needed
Do you have any dependents that need to be added to your plan January 1, 2024?
If yes, please list the name(s) of dependents to be added:
Use the + icon at the end of each row to add additional rows as needed
First Name Last Name Date of Birth Gender Tobacco Use

Use the + icon at the end of each row to add additional rows as needed

Consent for Broker Assistance
AS REQUIRED UNDER CMS-9899-F AMENDMENT OF 45 CFR § 155.220
Household Contact Information
Name of Primary Contact and/or Authorized Individual*
First Last
Phone*
Email*
Consent*
I give my permission to KHI Solutions, LLC and/or their staff to provide the following services on behalf of myself, and my entire household if applicable.
1. Search for an existing Marketplace application;
2. Completing an application for eligibility and enrollment in a marketplace Qualified Health Plan or
  government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace Premiums or enrollment in off-exchange insurance products as applicable.
3. Providing ongoing account maintenance and enrollment assistance, as necessary; or
4. Responding to inquiries from the Marketplace regarding my Marketplace application.
I understand that KHI Solutions, LLC and/or their staff will not share my personally identifiable information (PII) and they will ensure that my PII is kept private and safe when collecting, storing, and using my information for the stated purposes above.

I confirm that the information I provide for entry on my Marketplace eligibility and enrollment application will be true to the best of my knowledge.

I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time. I understand that requests must be made in writing, either by sending the request via certified mail to the address below or via email to [email protected].

KHI Solutions, LLC
Date*
MM slash DD slash YYYY
Primary Contact Signature*

Please note that submissions made via this website do not constitute a binding agreement of any kind. Coverage or changes in coverage are not effective or binding until you, or any party involved, receive official notice from an authorized representative of KHI Solutions or your insurance company. Misstatements or omissions of relevant information by the prospect/client can lead to price variation or even declination or rescission of coverage.

Medication Name	Tablet/Capsule (ER/XR)	Dose (mg, ml)	Daily Quantity Taken	How often refilled (30 day/90 day/Yearly)

Marketplace Review of Eligibility Application

Step 1 of 4

Do you have any dependents that need removed from your plan January 1, 2024?

Do you have any dependents that need to be added to your plan January 1, 2024?

Consumer Consent Acknowledgment

Consent for Broker Assistance

Household Contact Information

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First Name	Last Name	Date of Birth

First Name	Last Name	Date of Birth	Gender	Tobacco Use

Doctor’s First and Last Name	Specialty	Facility/City