Out-of-Hospital Patient Services (GP, Specialist), Prescription Drugs, Emergency Treatment, Rehabilitation and Equipment, Inpatient Services, Exam Services, Labor and Newborn Care, Preventive and Health Services and Chronic Disease Management, Mental Health and Drug Addiction Treatment services, including behavior modification, pediatrics, including dental and vision (children).

Please prepare the following information • Information of your family members (social security number/date of birth)
• Actual residential address and mailing address of family members • Immigrant identification documents (citizenship/green card/EAD card/I797/I94 or other immigration identification documents)
•Tax information (last year's tax bill/W2/1099…)
•Employer information and household income information •Estimated income for next year •If you have insurance next year, please provide old insurance information

Individual health insurance tax credit (Premium Tax Credit) income provides a family income between 100% and 400% of the Federal Poverty Level (FPL), and can receive tax credits. Estimated household income for the next year.
*If household income falls between 100% to 400% of the Federal Poverty
Level, you can qualify for Premium Tax Credit. Estimate 2021 household income.
Filer1 $12,880 - $51,520 Filer5 $31,040 - $124,160
Filer2 $17,420 - $69,680 Filer6 $35,580 - $142,320
Filer3 $21,960 - $87,840 Filer7 $40,120 - $160,480
Filers4 $26,500 - $106,000 Filers8 $44,660 - $178,640