Client Intake Form - NexPath Health Advisors

Client Intake Form

Please complete this short form so we can review your coverage options. Your information is secure and used only for your consultation.

Important Notice & Disclaimer

This form is for informational and consultation purposes only. Submission of this form does not constitute an application for insurance, establish coverage, or create a binding agreement. No insurance can be bound, changed, or canceled through this form. All information provided will be used to prepare a personalized consultation and coverage review. By submitting this form, you acknowledge that:

You are requesting a no-obligation consultation to discuss health insurance options.
The information you provide is accurate to the best of your knowledge.
NexPath Health Advisors and its agents are not liable for coverage recommendations until a formal application is submitted and accepted by a carrier.
Your personal information will be kept confidential and used solely for the purpose of providing insurance guidance.

I understand and agree to the terms above.

1. Contact Information

Primary Contact Name

Date of Birth

Preferred Contact

Street Address

City

State

ZIP

Phone

2. Household Income

Estimated annual household income helps us identify subsidy eligibility and plan affordability. This is not binding and will be verified during enrollment.

Household Size (Total People)

Estimated Annual Household Income

Primary Income Source

💡 Income affects eligibility for premium tax credits and cost-sharing reductions. We'll review detailed documentation later if you qualify.

3. Household Members

Include everyone who should be considered for coverage.

Name	Date of Birth	Relationship	Tobacco (Y/N)

Tip: Add spouse and children you want considered for coverage.

4. Pre-Existing Conditions

Please list any chronic conditions, major diagnoses, or ongoing treatments for household members seeking coverage.

Household Member	Condition / Diagnosis	Treatment Status

Examples: diabetes, hypertension, asthma, cancer treatment, mental health care, etc.

5. Current Coverage

Dual Coverage? Turn on if spouses or other adults have separate plans.

A) Primary Policyholder

Name

Insurance Type

Carrier / Plan Name

Coverage Start

Renewal Date

6. Current Medications

Medication Name	Dosage	Frequency	Generic OK?

7. Preferred Doctors or Clinics

Provider / Clinic Name	Specialty	City / Location