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Health ACA Renewal Questionnaire
Marshall Tague
2023-03-08T10:36:02-07:00
Stewardship Health Insurance Renewal Questionnaire
Filling out this form helps us make sure you have the
right
plan in 2023.
Name
(Required)
First
Last
Email
(Required)
Please use the same email you use when working with Stewardship.
Do you use tobacco?
(Required)
Yes
No
Anticipated Annual Household Income for 2023
(Required)
(best estimation)
Do you have access to employer coverage?
(Required)
Yes
No
Doctor Name(s)
(Required)
List all doctor first and last names that you are currently seeing and would like to continue to see in 2023. If none put "none".
Prescriptions and Medications
(Required)
List all prescriptions and medications (generic name if available) you are taking along with the dosages for each. If none put "none".
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