DEVINHEALTHGUARD.COM

Texas Residents: Enroll in Affordable Health Coverage Today

Complete the secure form below and we'll process your enrollment

Secure & Confidential
Licensed enrollment assistance
We handle the paperwork for you.

Healthcare Marketplace-Standard Silver-HMO

Plan Year: 2026 - (See If You Qualify)

Household Size-Include yourself, your spouse if married, and anyone you'll claim as a tax dependents in 2026 - even if they dont need coverage - then estimate income range for everyone you included in your household. *

Primary Application *

First Name / Last Name

Applying *

Yes

No

Gender *

Male

Female

Date of birth *

Social Security Number *

Address *

Street Address Line 2

City

State

Zip Code

Email

Phone Number *

What is your annual income? *

$0 - $20,000

$20,001 - $40,000

$40,001 - $60,000

$60,001+

Dependents

Spouse - NAME / D.O.B / SSN
Dependent 1 - NAME / D.O.B / SSN
Dependent 2 - NAME / D.O.B / SSN
Dependent 3 - NAME / D.O.B / SSN
Dependent 4 - NAME / D.O.B / SSN

Auto-Renewal Acknowledge

Good news! You can now opt-in for hassle-free health insurance renewal. By choosing auto-renewal, you won't need to worry about missing a beat in your coverage.

Auto Renewal *

YES

NO

Signature

Clear

Have questions before enrolling

Call or text us for assistance before submitting your information.

Call 561-229-4368

Email: [email protected]

Site: www.DevineHealthGuard.com