BQ+ Healthcare Navigation Program Eligibility Form This form will allow for us to schedule you an appointment to meet with a healthcare navigator. Today's Date MM slash DD slash YYYY Name(Required) First Last Pronouns He/Him/His She/Her/Hers They/Them/Theirs All apply Other(not listed) Date of Birth MM slash DD slash YYYY Upon review of this form how would you prefer to be contacted by a marketplace healthcare navigator ? Please check all that apply.(Required) Call Text Email Phone(Required)Email(Required) Do you have healthcare coverage?(Required) Yes No Is healthcare coverage offered by your employer?(Required) Yes No Unsure Currently unemployed Do you currently have a marketplace account?(Required)The marketplace account would be found on healthcare.gov Yes No Unsure Currently unemployed Number of people in the household (Self) 2 or more Adults 1 or more Children Are you currently employed?(Required) Yes No Yearly IncomeNo incomeUnder 1,000 a year1,000-10,00010,000-20,00020,000-50,00050,000-80,00080,000-100,000Over 100,000 a yearYour income may change throughout the year. Please give a good estimate of the range. Which of the following barriers are you facing for access to care? Transportation Affirming care Income Employment Anti-SPAM: What is 6 + 4?(Required)NameThis field is for validation purposes and should be left unchanged.
