ACA Consumer Consent: CMS requires health insurance agents to obtain a customer's consent before assisting them in applying for a subsidy and/or enrolling in a Qualified Health Plan (QHP) through the Marketplace. By submitting this request, you authorize the above-named agent to assist you in the health insurance enrollment process.
I attest that I grant permission to the above-listed agent to serve as my health insurance agent or broker, and if applicable, for my entire household, for the purpose of enrollment in a Qualified Health Plan (QHP) offered through the Federally Facilitated Marketplace (FFM). By consenting to this agreement, I authorize the agent to view and use the confidential information provided by me in writing, electronically, or by telephone only for one or more of the following:
-Searching for an existing Marketplace application.
-Completing an application for eligibility and enrollment in a Marketplace QHP or other government insurance affordability programs, such as Medicaid and CHIP, or advance tax credits to help pay for Marketplace premiums.
-Providing ongoing account maintenance and enrollment assistance, as necessary; or
-Responding to inquiries from the Marketplace regarding my Marketplace application.
I understand that the Agent will not use or share my personally identifiable information (PII) for any purpose other than those listed above. The Agent will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above.
I confirm that the information I provide for entry on my Marketplace eligibility and enrollment application will be true to the best of my knowledge. I understand that I do not have to share additional personal information about myself or my health with my Agent beyond what is required on the application for eligibility and enrollment purposes. I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by notifying the agent.
Acknowledgement of Roles and Responsibilities of the Agent: The enrollment process includes the collection of PII for all individuals listed on the health enrollment application. By checking the box, you are acknowledging consent to proceed.
I have been informed that I understand the agent roles and responsibilities listed above and have been given the opportunity to discuss them with the agent.
