MyHealth Coverage Connect

2026 Enrollment and Consent Form - LaGarret George
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Step 1 of 6
I understand this is a Marketplace Application to obtain Health Insurance. I understand I'm required to provide true answers and that I may be asked to provide additional information, including proof of my eligibility for a Special Enrollment Period if I qualify. If I don't , I may face penalties, including the risk of losing my eligibility for coverage.
Have you used tobacco in the last 6 months?
Will you file a tax return in next year?
Are you filed as a dependent?
I understand I may owe the IRS if I inaccurately report my income.
US Citizen
Date of Birth
Clear Signature