Health Coverage Registration - ViaOne ConnectCare

Health coverage is just a few quick steps away!

By entering the phone number and email address above, I authorize and give express consent to being contacted by ViaOne ConnectCare for marketing purposes during the Application Process. I may be contacted for this purpose via email, telephone, or text messaging, including calls or messages using an automated telephone dialing system, manually, or with pre-recorded/artificial voice messages. I also provide express consent to be contacted, regardless of whether my number is listed on the Do-Not-Call Registry or a state equivalent registry. Consent to such contacts is not a condition of service and may be revoked at any time. Message and data rates may apply. Message frequency varies. For contacts received via text message, reply HELP for help or STOP to cancel, or click the unsubscribe link (where available) in any text message. I will receive a one-time opt-out confirmation text message. I may also revoke consent by calling (866) 824-4245, or by following the opt-out instructions in an email message. For more information see Terms and Conditions and Privacy Policy at www.viaoneconnectcare.com/terms.

Next Step

Are you currently receiving Medicaid?

Yes

No

Next Step

Have you received notice that your Medicaid benefit will be expiring at the end of the month?

Yes

No

Next Step

Do you see your income increasing or starting a new job in the next 90 days?

Yes

No

Next Step

Are you interested in moving your Medicaid health benefit to an ACA benefit plan?

Yes

No

Next Step

Are you currently receiving Medicare?

Yes

No

Next Step

Consent to Share Data with ViaOne ConnectCare

Next Step

I hereby give my permission to ViaOne ConnectCare (Brayden Quirple NPN #21003603), as mentioned in this agreement, to serve as the health insurance agent or broker for myself and my entire household, if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace. By consenting to this agreement, I authorize and its affiliates to: View and use the confidential information provided by me in writing, electronically, or by telephone for the purposes of: Searching for an existing Marketplace application. I consent to receiving automated phone calls, SMS, and email messages using templated messages or Artificial Intelligence (AI) to help collect information or communicate with me. Standard message and data rates may apply, messaging frequency varies, and consent is not a condition of purchase. Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs. Providing ongoing account maintenance and enrollment assistance, as necessary. Responding to inquiries from the Marketplace regarding my application. Act as my Agent of Record concerning all matters related to my health insurance. This designation allows the Agent and its affiliates to represent and assist me in all interactions with the health insurance provider. Ensure that my Personally Identifiable Information (PII) is kept private and safe when collecting, storing, and using it for the above purposes. and its affiliates commit to not sharing my PII for any purposes other than those explicitly stated in this agreement. I further attest to one or more of the following conditions being true: My income meets the minimum required to qualify for subsidized healthcare under the Federally Facilitated Marketplace. I, or someone in my household, have experienced a qualifying life change in the past 60 days that qualifies for a Special Enrollment Period. I, or someone in my household, either lost qualifying health coverage in the past 60 days or expect to lose coverage in the next 60 days. Scope of Appointment: I appoint ViaOne ConnectCare (Brayden Quirple NPN #21003603) as my representative for up to 5 years for the above-mentioned purposes. I grant the parties mentioned to contact me via phone, email, and/or text. Revocation: I understand that my consent remains in effect until I revoke it. I may revoke or modify my consent at any time by contacting 888-378-9794. Reply STOP to opt-out and unsubscribe from SMS messages. I consent to allow my new Agent of Record (AOR) to send letters, emails, and phone calls on my behalf for the purpose of contacting and revoking any previous AOR from accessing my private information or attempting to change AOR or plans without my express verbal and signed consent.

Next Step

Please review your information before submitting.

First Name

Date of Birth

Last Name

Social Security Number

Email

Phone

What type of plan do you need?

Individual

Family

Address 1

City

Address 2

State

Zip Code

What is your employment status?

What is your annual income?

Current medications

Are you currently enrolled in Medicaid?

Yes

No

Current physician

Are you a smoker?

Yes

No

Are you prescribed any medication(s)?

Yes

No

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Get Started

Health coverage is just a few quick steps away!

Are you currently receiving Medicaid?

Have you received notice that your Medicaid benefit will be expiring at the end of the month?

Do you see your income increasing or starting a new job in the next 90 days?

Are you interested in moving your Medicaid health benefit to an ACA benefit plan?

Are you currently receiving Medicare?

Income

Who is this policy for?

What is the policy holder address?

What is your medical history?

What type of plan do you need

Please provide the qualifying dependent information.

Please upload a valid form of photo identification.

Consent to Share Data with ViaOne ConnectCare

Please review your information before submitting.

We're sorry, but you are not currently eligible to be assessed for ACA Health Insurance due to Medicare or Medicaid enrollment.

I'm sorry, but you are not currently eligible to be assessed for ACA Health Insurance due to Income and Employment Status.

Your request has been submitted successfully!

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Get Started

Health coverage is just a few quick steps away!

Are you currently receiving Medicaid?

Have you received notice that your Medicaid benefit will be expiring at the end of the month?

Do you see your income increasing or starting a new job in the next 90 days?

Are you interested in moving your Medicaid health benefit to an ACA benefit plan?

Are you currently receiving Medicare?

Income

Who is this policy for?

What is the policy holder address?

What is your medical history?

What type of plan do you need

Please provide the qualifying dependent information.

Please upload a valid form of photo identification.

Consent to Share Data with ViaOne ConnectCare

What data will the Company collect?

Does my consent expire?

Does the Company control the data shared with the Agent/Broker?

My Consent to Receive Communications from ViaOne ConnectCare

Please review your information before submitting.

We're sorry, but you are not currently eligible to be assessed for ACA Health Insurance due to Medicare or Medicaid enrollment.

I'm sorry, but you are not currently eligible to be assessed for ACA Health Insurance due to Income and Employment Status.

Your request has been submitted successfully!