 Application Detail |
| Application Name | Individual Application 2016-09-28T05:00:469 | Application Reference Number | A-00091937 |
| Application # | A-00091937 | Internal Status | Termed |
| Opportunity | External Status | Termed | |
| Exchange Application # | EPP_147547 | Type | Individual Health |
| Plan Selected | NH HMO-ElevateHealth Individual | Agency Member No | 71179376117NH |
Subscriber Information
| Date of Birth | 6/16/1995 | Requested Coverage Effective Date | 10/31/2016 |
| Requesting Dependent Coverage | No | ||
| Tobacco Use | No |
Applicant Information
| Salutation | First Name | Victoria | |
| Middle Name | Last Name | Brown | |
| Suffix | Gender | Female | |
| Social Security Number | XXX-XX-5032 |
Address Information
| Physical Street | 10 Leathers LAN | Mailing Street | Webster Mills ROA 10 leathers lane C/O Victoria Brown |
| Physical City/Town | Dover | Mailing City / Town | Dover |
| Physical State | NH | Mailing State | NH |
| Physical ZipCode | 03820 | Mailing ZIP Code | 03258 |
Phone And Email
| HomePhone | (603) 731-1794 | Mobile Phone | |
| Work Phone | torie333@hotmail.com.sit | ||
| Additional Email |
Broker Information
| Broker | BrokerNPN | ||
| Agent ID / Vendor ID |
PCP Information
| PCP ID# | PCP Name | ||
| PCP City/Town | PCP Last Name | ||
| Current Patient |
Payment Description
| Payment Transaction id | |||
| Created By | System, 9/28/2016 8:00 AM | Last Modified By | Ashutosh Tiwari, 12/17/2021 12:31 PM |
| |
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