Update Your Doctors & Medications

A quick, secure way to keep your information up to date. Just complete the form and tap “Send.”

Please note: filling out this form does not automatically enroll you in a new plan. You'll still need to contact us to review plan options or make any changes to your coverage — this form is just to streamline and speed up that process.

01 Your Information

Full name

Date of birth

Phone number

Email (optional)

02 Health & Coverage Snapshot

This helps us flag the right plan options for you — it's not a medical record, just a quick check.

Are you currently enrolled in Medicare?

Yes No

Are you currently enrolled in Medicaid?

Yes No

Do you have any of the following: diabetes, a heart condition, or a lung condition?

Yes No

Estimated annual household income (AGI) (optional)

This helps us check whether you qualify for premium savings or subsidies.

03 Current Doctors

List every doctor you currently see — primary care and specialists.

04 Current Prescription Medications

List every prescription medication you currently take.

05 Anything else?

Notes (optional)

Marketplace Consumer Consent

By signing below, the following authorization applies to any Marketplace (ACA) assistance we provide:

Electronic signature (type full name)

Date

🔒 Sent over a secure, encrypted connection — not by regular email.

Something went wrong sending this securely. Please copy the summary below and email it to customerservice@insurehb.com or call us at 754-222-2207 instead.