Check to see if you qualify for a

$0 PER MONTH Health Plan!

Most people have no idea that they qualify for existing programs. That’s because although the programs are great, their outreach usually isn’t.

Let me be your guide navigating these programs to find the health plans that fit your medical and financial needs.

Before we start, we need your consent to continue.

We take your privacy and security seriously. All personal information provided is protected in accordance with HIPAA (Health Insurance Portability and Accountability Act) regulations. We ensure that your data is encrypted and stored securely. Rest assured, we do not share your information with any third parties without your consent. Your privacy is our priority.

I authorize the mentioned entities/persons to access my records and reach out to me for the purpose of assessing my eligibility, providing information on insurance options, and arranging an appointment or method to review and sign an insurance application. I am aware that confidential information will not be disclosed to any other outside party besides those specified.

Enter your referral's name so we can send them a THANK YOU NOTE!

Referral

File Upload

Upload File

You can attach an image of your Drivers License / Social Security Card / Paycheck / Other required documents here.

What you will need:

• Mailing address (if different from your license address)

• Phone number

• Email address (we can assist you to create one if you do not have any as it is required)

• Combined Total Household Income (Please only include income from dependents in your IRS Tax Return).

• Dependent Name and Dependent date of Birth of everyone (spouse and dependents) in your tax return household

• Paychecks of the applicant and members of the family in the tax return.

Do you already have Medicare? Medicare is not NJ FamilyCare (Medicaid). You would have a card like the one below.

YES

Are you 65 or older?

YES

Has the Social Security Administration determined you disabled or do you want to be evaluated by the Division of Medical Assistance and Health Services due to a permanent disability?

YES

Are you in your 24 month waiting period to receive Medicare?

YES

Are you a resident of New Jersey?

YES

Contact information:
Tell me a little bit about you and your family.

We will reach out to you to let you know what type of Health Insurance financial assistance program you qualify or to request further documentations.

Please enter your phone number and email address below where we can reach out at for the results.

Applicant First Name *

Applicant Last Name *

Applicant Phone Number *

Applicant Email

If you don't have an email account we can help create one for you. As this is required.

Applicant Residential Address *

Applicant Gender *

Applicant Date of birth *

Applicant Social Security Number *

If you're comfortable, please provide your SSN below. If not, feel free to call our office, and we'll be happy to assist you.

Marital Status *

Spouse Date of Birth

Spouse SSN

If you're comfortable, please provide your SSN below. If not, feel free to call our office, and we'll be happy to assist you.

Applicant Dependents

Please list only your dependents as listed on your IRS Tax Return and provide their NAME/s, DOB, & SSN. Also, check the box of those dependents who needs healthplan coverage.

Number of Dependents *

Dependent 1 Birthdate

Dependent 2 Birthdate

Dependent 3 Birthdate

Dependents who needs Health plan *

Applicant Monthly Income *

Before taxes, please provide the income information for your entire household, not just yourself, on your tax return. If you are self-employed, please specify your line of work and your net income (profits after business expenses) for this month. We request this income and other details to determine your eligibility for coverage and potential assistance. Rest assured, all information you provide will be kept private and secure, as mandated by law. If you are a senior receiving only SSA retirement benefits, please enter the amount of your SSA payment.

Spouse Monthly Income

Please include name and phone number of your primary care and specialist Doctor/s. Leave it blank if not applicable.

Family/Primary Doctor

Full Name
Phone Number
Address

Specialty Doctor 1

Full Name
Phone Number
Address
Specialization

Specialty Doctor 2

Full Name
Phone Number
Address
Specialty

What hospital do you go to?

Do you have an existing Health Insurance? *

YES

If yes, when was the last day of prior Health Insurance Plan?

Existing Medications/Conditions

Do you have any major health issues (High Blood Pressure, Diabetes, Asthma, Stroke, Etc)

Yes

Are you a U.S. citizen or a lawful permanent resident (Green Card holder)?

Yes

If you didn’t see a confirmation message after submit, please check that all required questions (*) are answered and try re-submitting again.

It's very important that you answer the phone or reply to the text messages from 856-528-8857 or 856-441-3536 so we can submit your application in a timely manner.

Visit www.medicareandmoney.com for more information.