ACA Health Coverage Eligibility — Check Your Options

What is your legal name as it appears on your driver's license?

First name *

Last name *

Please enter your first and last name.

Street address *

City *

State *

ZIP code *

Please enter your full address including street, city, state, and ZIP.

Email address *

Phone number *

Date of birth *

Social Security Number * 🔒 Used for identity and eligibility verification only.

Please complete all fields accurately — email, phone, date of birth, and SSN.

Gender *

👨Male

👩Female

🧑Non-binary

🤐Prefer not to say

Are you a US citizen? *

🇺🇸Yes

🌍No

📋Lawfully Present

Are you currently employed? *

💼Full-Time

🕐Part-Time

🏪Self-Employed

🔍Unemployed

🌴Retired

Your doctor's information

Doctor's first name

Doctor's last name

City where doctor is located

Please select your gender, citizenship status, and employment status.

Marital status *

🙋Single

💍Married

📋Divorced

🕊️Widowed

↔️Separated

Number of dependents (not counting yourself) *

Please select your marital status, complete all required information, and select number of dependents.

Estimated annual household income *

Do you use tobacco? (Can affect premiums by up to 50%) *

🚭No

🚬Yes

⏹️Former

Please select your income range and tobacco use.

Authorization to Act on Your Behalf By signing below, you authorize a licensed insurance agent to:

Research and present health insurance plan options on your behalf
Submit applications to insurance carriers with your consent
Contact you by phone, email, or text regarding your eligibility
Access your ACA Marketplace account for enrollment purposes

This authorization does not obligate you to enroll in any plan. You may revoke this authorization at any time.

I hereby give my permission to Fides Insurance, NPN 20510910, as mentioned in this agreement, to serve as the health insurance agent or broker for myself and my entire household, if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace. By consenting to this agreement, I authorize Fides Insurance and their affiliates to:

View and use the confidential information provided by me in writing, electronically, or by telephone for the purposes of: Searching for an existing Marketplace application; Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs; Providing ongoing account maintenance and enrollment assistance, as necessary; and Responding to inquiries from the Marketplace regarding my application.
Act as my Agent of Record concerning all matters related to my health insurance. This designation allows Fides Insurance and their affiliates to represent and assist me in all interactions with the health insurance provider.
Ensure that my Personally Identifiable Information (PII) is kept private and safe when collecting, storing, and using it for the above purposes. Fides Insurance and their affiliates commit to not sharing my PII for any purposes other than those explicitly stated in this agreement.

I further attest to one or more of the following conditions being true: My income meets the minimum required to qualify for subsidized healthcare under the Federally Facilitated Marketplace; I, or someone in my household, have experienced a qualifying life change in the past 60 days that qualifies for a Special Enrollment Period; or I, or someone in my household, either lost qualifying health coverage in the past 60 days or expect to lose coverage in the next 60 days.

Scope of Appointment: I appoint Fides Insurance, NPN 20510910, as my representative for up to 10 years for the above mentioned purposes. I grant the parties mentioned to contact me via phone, email, and/or text.

Revocation: I understand that my consent remains in effect until I revoke it. I may revoke or modify my consent at any time by contacting Fides Insurance at sethvanfossen1@gmail.com

* By checking this box I confirm I have read and agree to the above authorization.

By submitting this form, I provide my signature expressly consenting to be contacted by a representative of this form at the number I have provided. I understand these communications may be made using an automated technology, including but not limited to an auto-dialer. This consent is not required as a condition of purchasing any goods or services. I agree that such calls and messages may be made to assist me in purchasing or obtaining information about health insurance plans, to receive updates, and to be informed about changes to my plan or services as necessary. *

Notice: I understand that I may be required to verify the information provided in this attestation. I must attest that the information I provide is true, including the facts that qualify me for enrollment. I may be required to submit documents that confirm my eligibility based on the conditions I've attested to. By signing above, I acknowledge the terms and conditions outlined in this attestation.

Type your full legal name as your electronic signature *

By typing your name above, you are signing this authorization electronically. This electronic signature is legally binding under the ESIGN Act.

📅 Signed on:

Please check all required boxes and type your full name to sign.

Household	100% FPL	Medicaid (138%)
1 person	$15,060	$20,782
2 people	$20,440	$28,207
3 people	$25,820	$35,632
4 people	$31,200	$43,056
5 people	$36,580	$50,480

Find out if you qualify for free health coverage

Your contact information

You're all set!

🛡️ What you may qualify for

📊 2026 FPL income guidelines

🔒 Your privacy