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SHF 2016
| HEALTH INSURANCE MARKETPLACE ASSISTANCE
NOV 1, 2016 - JAN 31, 2017
STEP 1: CONTACT INFORMATION
DATE OF REQUEST:
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First Name
*
Last Name
*
Address
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City
*
STATE
*
🛈
TEXAS
OTHER
Postal Code
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Cell Phone or Primary Phone
*
🛈
Email Address:
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Language Fluency:
*
🛈
Speak
Write
Yes
No
Yes
No
English
Yes
No
Yes
No
Spanish
Yes
No
Yes
No
Other
Yes
No
Yes
No
How would you like to receive assistance with the new health insurance markets?
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In Person (Schedule Appointment)
Phone
Internet / Website
Location Closest To You
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Bellaire Health Center (Bellaire-southwest)
Conroe Health Center (Conroe-north)
Greenspoint Health Center (North Houston)
Savoy Corporate Office (Houston-southwest)
Sugarland Health Center (Sugarland-southwest)
Texas City Health Center (Texas City-southeast)
Best Day of Week To Contact You:
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MONDAY
TUESDAY
WEDNESDAY
THURSDAY
Select Best Time To Contact You:
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1:30 PM
2:00 PM
2:30 PM
3:00 PM
3:30 PM
4:00 PM
4:30 PM
Brief Summary of Assistance Requested:
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