Let’s See If You Qualify For Free Health Insurance

Most Mississippi residents qualify for $0 coverage. Fill out the form below — it only takes 2 minutes.

First Name *

Last Name *

Phone *

Email *

I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from company. Message frequency varies. Message & data rates may apply. Text HELP to (601) 803-8262 for assistance. You can reply STOP to unsubscribe at any time.

Date of birth *

Gender *

Citizenship Status *

Social Security Number

Street Address *

City *

State *

Postal code *

Do You Have Dependents? *

Number Of Dependents

If you have dependents, for each dependent enter their FULL NAME, DATE OF BIRTH, & SOCIAL SECURITY NUMBER

Employment Status *

Employer Name / Company / Self

Other Income Sources (If You have)

SSI

Pension

Farm/Fishing

Income

Income Type

“I certify the information provided is accurate and give consent for my ACA application to be processed.”

I Agree

By submitting this form, I authorize Sedgie Foxworth NPN #: 640015 to access and use my personal information to search for and complete an application for a Qualified Health Plan through the Federally Facilitated Marketplace (HealthCare.gov). I understand this consent applies to myself and any listed household members and can be revoked at any time. This information will be used solely for application, enrollment, and ongoing assistance.

“I understand and agree to the terms above.”

Today's Date *

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