Health Insurance Enrollment
Today's Date
*
mm/dd/yyyy
First Name
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Last Name
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Date of Birth
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mm/dd/yyyy
Email
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Phone
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Phone
Location
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Preferred Language
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Household Size
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What insurance do you currently have?
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Which of the following are you interested in?
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Please check all that apply.
Health Insurance Marketplace (healthcare.gov)
AHCCCS or KidsCare
Supplemental Nutrition Assistance Program (SNAP, formerly known as food stamps)
Temporary Assistance for Needy Families (TANF, also known as cash assistance)
I'm not sure
How do you prefer to meet?
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In-person
Phone
How did you hear about us?
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By checking this box, I understand that it may take up to two business days to receive a response from North Country HealthCare. If this is an urgent request, I will contact the location nearest me by telephone.
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By checking this box, I understand that making contact with North Country HealthCare through our website does not create a patient/medical provider relationship and does not make you a patient of North Country HealthCare.
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