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? ________