Affordable Care Act Questionnaire Form printable pdf download

Affordable Care Act Questionnaire Form

Affordable Care Act Questionnaire

What (if any) health insurance did you or your dependents have in 2014?

(Attach a copy of your insurance card or bring it to your appointment)

1. ____Medicare

2. ____Medicaid (Badger Care)

3. ____Private employer

4. ____Private insurance

5. ____Government Marketplace

6. ____Other (Such as Veterans Affairs) ____________________________

List all members of the family. For each member list the months (if any) he or she

did not have health insurance (if a member had health insurance for one day

during the month, he or she is treated as having insurance for the entire month)

Family member

Months not covered

_____________________________ _________________________________

Did you receive a Form 1095? Yes___ No____ (If yes, attach a copy or bring it to

your appointment)

If you have insurance from the Government Marketplace:

a. How many children are your dependents? ____

(Attach a copy of their tax return(s) if they filed or bring it to your

appointment)

b. How many children are dependents of another taxpayer? ____

c. Did you receive a subsidy from the Marketplace that reduced the monthly

premium for your insurance (also called an Advance Premium Tax Credit)?

Yes ____ No ____ If yes, what was the monthly subsidy? ________

Affordable Care Act Questionnaire Form