MidSouth Health Insurance

Who would you like to insure?

Single

Couple

Family

Single Family

Choose your state

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Do you currently have any of the following health insurance coverage?

What is the gross monthly income range for your household?

Your monthly income BEFORE taxes, benefits and other payroll deductions

What is the exact gross monthly income for your household?

Please be accurate - income will be verified by healthcare.gov

Please specify an answer

$0 Premium Healthcare For

Those Who Qualify - Find Out Now!

Enter your details to start your health insurance application

First name

Please enter your first name

Last name

Please enter your last name

Email address

Please enter a valid email address

I agree with the terms and condition and I'm also happily subscribing to your newsletter.

We will text or email if there is an issue with your new health insurance. Plan information will come via postal mail.

Application will take *5 minutes

Your contact details

First name

Please enter your first name

Last name

Please enter your last name

Email address

Please enter a valid email address

Please specify medical issues

Please specify an answer

Your details

First name

Please enter your first name

Last name

Please enter your last name

Date of Birth

Please select a date.

Gender*

Female

Male

Are you a United States citizen?*

Yes

Are you a tobacco user?* (tobacco users pay higher premiums)

Yes

Social Security Number*

Please specify an answer

Most recent employer*

Please specify an answer

Do have any dependents?*

Yes

Your dependent's detaiils

Dependent 1

First name

Please enter your first name

Last name

Please enter your last name

Relationship to applicant

Date of birth

Please select a date.

Social Security Number* (If you have a social security number you must provide it)

Please specify an answer

I do not have a social security number

I attest that I don't have a SSN because one was never issued to me by the Social Security Administration

Dependent 2

First name

Please enter your first name

Last name

Please enter your last name

Relationship to applicant

Date of birth

Please select a date.

Social Security Number* (If you have a social security number you must provide it)

Please specify an answer

I do not have a social security number

I attest that I don't have a SSN because one was never issued to me by the Social Security Administration

Dependent 3

First name

Please enter your first name

Last name

Please enter your last name

Relationship to applicant

Date of birth

Please select a date.

Social Security Number* (If you have a social security number you must provide it)

Please specify an answer

I do not have a social security number

I attest that I don't have a SSN because one was never issued to me by the Social Security Administration

Your medical details

Are there any Doctors, Specialist or Providers that you want to remain in network? *

Yes

*if yes please list names, address and phone numbers below

Please specify an answer

Are there any prescription medications that you want to remain in network? *

Yes

*if yes please list below

Please specify an answer

Do you have any procedures or surgeries scheduled? *

Yes

*if yes please list below

Please specify an answer

If there are $0 plans you may qualify for and your doctor/provider/specialist is not part of the network, do you want to enrol in the best lowest premium plan they accept? *

I want a $0 premium (regardless of Doctor network).

Yes, I am willing to pay a premium to keep my doctor. Please enroll me in the lowest premium plan that has my Doctor in network.

Terms and Conditons

You attest that your estimated income for 2024 will be at least the Federal Poverty Limit for your state and household requirements. You agree to notify us as soon as you become aware of any changes to expected income per month that you provided above. Failure to notify us of any changes may result in your eligibility being affected.

In some cases, it may be necessary to verify your income. If income verification is required in order to complete your enrollment, do you authorize MidSouth Health Insurance Agency, LLC. to submit an income attestation letter on your behalf with the information that you have provided?

By supplying my initials and signing below, I hereby provide consent and authorization to MidSouth Health Insurance Agency, LLC. to enroll me and/or my family in a health insurance plan through the ACA Marketplace at no cost to me. I grant permission for MidSouth Health Insurance Agency, LLC to access my healthcare.gov account for the purpose of quoting, enrolling, and maintaining my health insurance. If I already have a plan, I request that Boost Health Insurance Agency, LLC. and its agents become my Agent Of Record and switch me to a better plan if one is available. This consent will remain in effect unless and until rescinded by you in writing, by emailing contact@midsouthhealthinsurance.com.

If we change your plan, you understand that your deductible and/or annual maximum out of pocket will start over again once your new policy begins. If you are not currently covered (you stated you did not have coverage currently at the beginning of the application), this will not apply/affect you.

If your income is $0 (or less than the Federal Poverty Limit), you attest that your estimated income for 2024 will be at least the Federal Poverty Limit for your state and household requirements. If your income will be less than (or greater than) those limits, you agree to notify us or the Marketplace of any changes or updates as soon as possible. Failure to notify us of any changes may result in your eligibility being affected. I agree to notify MidSouth Health Insurance Agency, LLC. if my estimated income for 2024 changes.

DISCLOSURES REGARDING LIMITED POWER OF ATTORNEY

The following limited power of attorney authorizes MidSouth Health Insurance Agency, LLC to make decisions concerning your health insurance. This limited power of attorney does not authorize MidSouth Health Insurance Agency, LLC or any other person to make decisions about your medical care.

The following limited power of attorney becomes effective immediately upon signing. If MidSouth Health Insurance Agency, LLC is unable or unwilling to act for you after you sign the limited power of attorney, we will notify you and this power of attorney will end.

Please review the limited power of attorney carefully. If you have questions about the power of attorney or the authority you are granting to MidSouth Health Insurance Agency, LLC you should seek legal advice before signing this form.

FORM OF LIMITED POWER OF ATTORNEY

I grant MidSouth Health Insurance Agency, LLC limited authority to take any and all actions to select, procure, and maintain health insurance for myself and any dependents though the Federally-Facilitated Marketplace (“FFM”), including, but not limited to the following actions:

Select a health plan for me;

Apply for and enroll me (and any dependents) in the selected health plan;

Add or remove coverage;

Create or change a beneficiary or dependent designation;

Update contact information for me and any dependents or beneficiaries;

Update information relevant to eligibility for subsidies for the health insurance;

Submit supplemental materials to a health insurance marketplace or exchange, including, but not limited to, proof of income and social security numbers;

Keep my health insurance in-force by renewing coverage from time to time;

Change the health plan at renewal if a better plan is available; and

Take any other action with regard to such health insurance as permitted by law.

The authority granted to MidSouth Health Insurance Agency, LLC hereunder will cease upon my death, incapacity, or if I revoke the power of attorney in writing to MidSouth Health Insurance Agency, LLC.

Any person, including, without limitation, MidSouth Health Insurance Agency, LLC, any web-broker through which Boost Health Insurance Agency, LLC may submit an application for insurance on my behalf, and the FFM, may rely upon the validity of this limited power of attorney or a copy of it unless that person knows it has been terminated.

By checking this box I provide my express consent to MidSouth Health Insurance Agency, LLC. and grant MidSouth Health Insurance Agency, LLC. and/or its agents a limited power of attorney to enroll me in a health insurance plan and to automatically enroll me in a plan at renewal.

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I hereby signify my agreement with the foregoing by electronically signing below

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Insurance

Who would you like to insure?

Choose your state

Do you currently have any of the following health insurance coverage?

What is the gross monthly income range for your household?

What is the exact gross monthly income for your household?

$0 Premium Healthcare For

Those Who Qualify - Find Out Now!

Your contact details

Your details

Your dependent's detaiils

Your medical details

Terms and Conditons

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