全民健保2026健保申请家庭状况变更表

2026 Health Insurance Change Request Form

特别提醒：收入核查也来越严，如果你没有报税记录，或者报税收入和本次申请的预估收入差距超过10%，不能再用“口头声明”作为收入证明，必须上传正式工资单、1099/W2表等硬核材料才可获得补助，否则保单和补助都会被拒。

Important Notice: Income verification is becoming more stringent. If you have no tax filing history or if your reported income differs by more than 10% from the estimated income stated in this application, you can no longer use a verbal declaration as proof of income. To qualify for benefits, you must upload hard-copy documentation such as official pay stubs or 1099/W2 forms. Failure to do so will result in your policy and benefits being denied.

I give my permission to Amy Insurance Group 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 the above-mentioned Agent to view and use the confidential information provided by me in writing, electronically, or by phone only for one or more of the following:

•    Searching for an existing Marketplace application

•    Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace premiums

•    Providing ongoing account maintenance and enrollment assistance, as necessary

•    Responding to inquiries from the Marketplace regarding my application

 I understand that the Agent will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The Agent will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above.

 •    I confirm that the information I provide for entry on my Marketplace eligibility and enrollment application will be true to the best of my knowledge.

•    I confirm that I have reviewed my completed application and that all information is accurate.

 I understand that I do not have to share additional personal information about myself or my health with my Agent beyond what is required on the application for eligibility and enrollment purposes. I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by contacting my Agent.

Name of primary writing Agent: Alena Wang       Agent NPN:       Phone#: 949-899-7609      Email address: califehelper@gmail.com