Enrollment Data Capture

Texas Medical Care Plans

Screenshot in, spreadsheet row out

Drop in an application or plan screenshot. Every field is read automatically, laid out for a quick review, then appended to your Google Sheet.

Click to upload screenshotsPNG or JPG, up to 6 images

Household

First name

Middle name

Last name

Gender

Tobacco

Age

Date of birth

SSN

Eligibility

Household size

Household income

Application year

Application ID

Application status

Members

Member 1 name

Member 1 relationship

Member 1 gender

Member 1 date of birth

Member 1 age

Member 1 ssn

Member 1 tobacco

Member 1 applying for coverage

Member 1 eligibility

Member 2 name

Member 2 relationship

Member 2 gender

Member 2 date of birth

Member 2 age

Member 2 ssn

Member 2 tobacco

Member 2 applying for coverage

Member 2 eligibility

Member 3 name

Member 3 relationship

Member 3 gender

Member 3 date of birth

Member 3 age

Member 3 ssn

Member 3 tobacco

Member 3 applying for coverage

Member 3 eligibility

Member 4 name

Member 4 relationship

Member 4 gender

Member 4 date of birth

Member 4 age

Member 4 ssn

Member 4 tobacco

Member 4 applying for coverage

Member 4 eligibility

Member 5 name

Member 5 relationship

Member 5 gender

Member 5 date of birth

Member 5 age

Member 5 ssn

Member 5 tobacco

Member 5 applying for coverage

Member 5 eligibility

Contact

Phone

Coverage county

Coverage state

ZIP code

Home address

Mailing address

Original agent

Plan

Carrier

Plan name

Plan type (HMO/PPO)

Metal level

Plan ID

Premium

Premium before subsidy

Subsidy / APTC

Cost-sharing reduction

Deductible

OOP max

Policy

Status

Effective

Expiration

Enrollment / submitted date

Policy members

Agent of record

NPN

Exchange ID

Policy ID

Subscriber ID

Member ID

Group number

Status

Payment

Payment status

Documents complete

Missing documents

Cards received

Action required

Medicare status

Follow-ups

Follow-up 1 item

Follow-up 1 status

Follow-up 1 member

Follow-up 1 deadline

Follow-up 1 action

Follow-up 2 item

Follow-up 2 status

Follow-up 2 member

Follow-up 2 deadline

Follow-up 2 action

Follow-up 3 item

Follow-up 3 status

Follow-up 3 member

Follow-up 3 deadline

Follow-up 3 action

Review & confirm, then push to Google Sheets

Spreadsheet URL or ID

Autopay?Check if the client agreed to automatic monthly premium payments. This value is sent to Google Sheets as Yes/No.

Preferred communication language

Sent to the HighLevel "Language" field so messages go out in the right language.