Pre-Appointment Financial Worksheet

* Indicates required field

Applicant Full Legal Name *

First

Last

Date of Birth (MM/DD/YYYY) *

Cell Phone *

Home Phone *

Email *

Physical Address *

Line 1

Line 2

City

State

Zip Code

Country

Mailing Address (if different from physical address) *

Line 1

Line 2

City

State

Zip Code

Country

What is the Source of income: *

When did this start: *

Gross income (monthly): *

Gross income (Annually): *

How often do you get paid: *

When was the last payment received: *

If income ended, when did it end: *

Additional income source(s): *

Spouse Full Legal Name *

First

Last

Date of Birth (MM/DD/YYYY) *

What is the Source of income: *

When did this start: *

Gross income (monthly): *

Gross income (annually): *

How often do you get paid: *

When was the last payment received: *

If income ended, when did it end: *

Additional income source(s): *

Dependents:

Child's Legal Name *

First

Last

DOB (MM/DD/YYYY) *

Gender *

Child's Legal Name *

First

Last

DOB (MM/DD/YYYY) *

Gender *

Child's Legal Name *

First

Last

DOB (MM/DD/YYYY) *

Gender *

Child's Legal Name *

First

Last

DOB (MM/DD/YYYY) *

Gender *

* Below 138% you could qualify for Medicaid - If your state expanded Medicaid
** Below 206% children under 19 could qualify for Medicaid (In Ohio)

Submit

(719) 481-1616
5390 North Academy Blvd.
Suite 220
Colorado Springs, CO 80918
Click Here to Email Us

Choice Enrollment
5390 North Academy Blvd.
Suite 220
Colorado Springs, CO 80918
(719) 481-1616
Click Here to Email Us