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CMYCMMYCYCMYKAPPLICATIONFORCAREATPASSIONCHIROPRACTICANDWELLNESSCENTER Whommaywethankforreferringyoutothisoffice? TodaysDate: PATIENTDEMOGRAPHICSHRN: Name: BirthDate: Age:
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To fill out the maritalstatus field, you need to provide one of the following options: single, married, divorced, or widowed. Select the option that best describes your current marital status.
02
To fill out the doyouhaveinsurance field, you need to provide a yes or no answer. Indicate whether you have insurance or not.

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Anyone who is completing a form or questionnaire that requires information about their marital status and insurance needs to fill out the fields maritalstatus single marrieddivorced widoweddoyouhaveinsurance.
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Marital status refers to whether an individual is single, married, divorced, or widowed, and if they have insurance coverage.
Individuals who are required to report their marital status and insurance coverage include taxpayers and individuals receiving insurance through the marketplace.
To fill out marital status and insurance information, individuals should provide accurate information on their tax return form or through the healthcare marketplace application.
The purpose of reporting marital status and insurance coverage is to determine eligibility for certain tax credits and subsidies, as well as track individuals' access to healthcare.
Individuals must report their current marital status, including any changes during the tax year, and provide information on their health insurance coverage, if applicable.
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