Jackie Hernandez

I am a hard working and motivated individual who lets his work speak for its self. I am always prepared to deliver reliable and precise services. History of meeting client expectations and completing tasks promptly, with focus on quality and adherence to safety standards. Values team collaboration and consistent performance, with flexibility to adapt. to changing project needs.

• Name: Lilly Prieto Dimoftache
• Email: lillyprieto90@gmail.com
• Phone: 7866005586
• NPN #: 20378309
• Agent #: 5996-175

• Group Members
• Jackie Hernandez Primary Applicant
• Teresa Hernandez
• Health Plan
• MyBlue Bronze 2219 ($0 Virtual Visits / Rewards $$$)
• Subsidized Monthly Premium: 0.0
• Additional Information
• MyBlue Bronze 2219 ($0 Virtual Visits / Rewards $$$): Medical Deductible: N/A
• Drug Deductible: N/A
• Combined Medical and Drug Deductible: Individual: $2,400 / Family: $2400 per person | $4800 per group
• Out-of-Pocket Max: Medical Benefits: N/A
• Drug Benefits: N/A
• Medical and Drug Benefits Total: Individual: $9,100 / Family: $9,100 per person | $18,200 per group

• If you require assistance reading this document, contact the agent at the number listed above in the Agent Contact Information section
• Eligible Applicant(s) Information
• Name Age Date of Birth Gender Relationship Zip Code
• Used Tobacco in the Past?
• Jackie Hernandez 39 03/20/1984 Male Self 32207 Never
• Teresa Hernandez 34 01/01/1989 Female Spouse 32207 Never
• Used Tobacco in the Past? : Refers to any use of tobacco (e.g., cigarettes, cigars, pipes, snuff, or chewing tobacco) in the past 6 months, four or more times per week on average, except for religious or ceremonial uses.
• Responsible Subscriber - Jackie Hernandez
• First Name: Jackie
• MI :
• Last Name : Hernandez
• Suffix :
• Date of Birth : 03/20/1984
• Gender : Male
• Used Tobacco in the Past?: Never
• Doctor/Facility Details: ST VINCENTS AMBULATORY CARE INC1 MCCLOUD, JOSSIE A 3 SHIRCLIFF WAY STE 615 Jacksonville, Florida - 32204 (904) 308-1670

• Street Address: 4709 Putnam Ave
• City: Jacksonville
• State: FL
• Zip Code: 32207
• County: DUVAL

• Primary Phone Number: 561-335-4876 (Home)
• Secondary Phone Number: ()
• Your email address is required because you are applying online. If you prefer not to provide an email address, you can request to submit a paper application.
• Applicant Email Address: none@gmail.com

• First Name: Teresa
• MI:
• Last Name: Hernandez
• Suffix:
• Date of Birth: 01/01/1989
• Gender: Female
• Used Tobacco in the Past? : Never
• Doctor/Facility Details: ST VINCENTS AMBULATORY CARE INC1 MCCLOUD, JOSSIE A 3 SHIRCLIFF WAY STE 615 Jacksonville, Florida - 32204 (904) 308-1670

• Individual Enrollment 1
• Consent to Electronic Contract
• Please remember that you can call us to ask for a free paper copy of your completed application.
• You agree to submit your application electronically to Florida Blue HMO, a Health Maintenance Organization affiliate of Blue Cross and Blue Shield of Florida, Inc. You are also agreeing to receive email communications from Florida Blue HMO about your application.
• You have the right to withdraw this consent at any time. You can withdraw your consent by clicking on the "Disagree" button or by discontinuing this application.

• I understand that because advance payments of the premium tax credit will be paid on my behalf to reduce the cost of health coverage for myself and/or my dependents:
• I must file a federal income tax return in 2024 for the tax year 2023.
• If I'm married at the end of 2023, I must file a joint income tax return with my spouse, unless an exception applies.
• I also expect that no one else will be able to claim me as a dependent on their 2023 federal income tax return.
• I'll claim a personal exemption deduction on my 2023 federal income tax return for any individual listed on this application as a dependent who is enrolled in coverage through this Marketplace and whose premium for coverage is paid in whole or in part by advance payments of the premium tax credit for which I am the applicable taxpayer.
• If any of the above changes, I understand that it may impact my ability to get the Premium Tax Credit.
• I also understand that when I file my 2023 federal income tax return, the Internal Revenue Service (IRS) will compare the household income on my tax return with the household income on my application. I understand that if the household income on my tax return is lower than the amount of expected household income on my application, I may be eligible to get an additional Premium Tax Credit amount. On the other hand, if the income on my tax return is higher than the amount of income on my application, I may owe additional federal income tax.
• I acknowledge that the Health Insurance Marketplace application, which included my income information, was completed by the identified Agent. The Agent completed this application and attested on my behalf with my express verbal permission, or with the permission of my designated proxy.
• I, Jackie Hernandez, Primary Tax Filer, have read and understand the above statements.
• Applicant Agrees Applicant Disagrees
• I, Teresa Hernandez, Joint Tax Filer, have read and understand the above statements.

• We comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. We do not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
• We provide:
• Free aids and services to people with disabilities to communicate effectively with us, such as:
• Qualified sign language interpreters
• Written information in other formats (large print, audio, accessible electronic formats, other formats)
• Free language services to people whose primary language is not English, such as:
• Qualified interpreters
• Information written in other languages
• If you need these services, contact:
• Health and vision coverage: 1-800-352-2583
• Dental, life, and disability coverage: 1-888-223-4892
• Federal Employee Program: 1-800-333-2227
• If you believe that we have failed to provide these services or discriminate on the basis of race, color, national origin, disability, age, sex, gender identity or sexual orientation, you can file a grievance with:
• Health and vision coverage (including FEP members):
• Section 1557 Coordinator
• 4800 Deerwood Campus Parkway, DCC 1-7
• Jacksonville, FL 32246
• 1-800-477-3736 x29070
• 1-800-955-8770 (TTY)
• Fax: 1-904-301-1580
• Section1557coordinator@floridablue.com
• Dental, life, and disability coverage:
• Civil Rights Coordinator
• 17500 Chenal Parkway
• Little Rock, AR 72223
• 1-800-260-0331
• Civilrightscoordinator@fclife.com
• You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Section 1557 Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at http://ocrportal.hhs.gov/ocr/portal/lobby.jsf, by mail or phone at:
• U.S. Department of Health and Human Services
• 200 Independence Avenue, SW
• Room 509F, HHH Building
• Washington, D.C. 20201
• 1-800-368-1019
• 1-800-537-7697 (TDD)
• Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html
• Health and Vision insurance is offered by Florida Blue.HMO coverage is offered by Florida Blue HMO, an affiliate of Florida Blue. Dental, Life and Disability insurance is offered by Florida Combined Life Insurance Company, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent Licensees of the Blue Cross and Blue Shield Association.
• 86763 0616
• Florida Blue and Florida Blue HMO (health and vision coverage): 1-877-465-1125
• Florida Combined Life (dental, life, and disability coverage): 1-888-223-4892
• TTY: 800-955-8770
• Have a disability? Speak a language other than English? Call to get help for free.
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