Consumer Authorization Form
The Department of Health and Human Services requires licensed sales agents to obtain consumer consent before providing assistance to Marketplace consumers. By signing this form, you acknowledge that the agent has informed you of the roles and responsibilities of agents in the Marketplace, and you grant permission to the authorized licensed sales agent to do the following
I, Mr./Mrs. __________________________, request help enrolling in health insurance through the Health Insurance Marketplace. I have provided information needed to be eligible for the health insurance marketplace tax credit for reduced premium benefits. I certify that I have received and understood the advice provided by:
Agents and/or Entities: Anna Paz, Annerys Camacho, Iralis Masabet, Simon Urdaneta & Unlimited Insurance & Financial Services
NPN: 20683552, 18332951, 20769395 & 20849847
I hereby give my permission and authorize the agents and entities specified above to act as a health insurance agent or broker for me and my entire family, if applicable. By consenting to this agreement, I authorize you to view and use the confidential information provided by me in writing, electronically, or by telephone, which shall be safeguarded and protected by all possible means only for the purposes of one or more of the following:
1.Search and/or creation of an application in the Insurance Marketplace or other products or services that may be of interest to me;
2.Complete an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay Marketplace premiums;
3. Provide ongoing account maintenance and enrollment assistance, as needed;
4. Respond to inquiries from the Marketplace regarding my Marketplace request.
5. Contact me about other content that may be of interest to me.
I have reviewed all the information required for the submission of my application. I also understand that in the event of changes to the information provided below or any other, I must notify my representative immediately to update my request.
I confirm that I do NOT have other health insurance, as well as that I have no offer at my job for medical coverage.
Please note that I wish to appoint Anna Paz as my insurance agent for the requested effective date and for the lines of business currently in effect. This form supersedes any prior authorization.
I sign this consent under penalty of perjury, which means that I have provided truthful answers to all questions to the best of my knowledge. I know that I may be subject to penalties under federal law if I intentionally provide false information.
EXCEPTIONS OR LIMITATIONS TO CONSENT: I understand that I may revoke, limit, or change the consent I provide through this form at any time. If I do not make any limitations, exceptions, or changes to my consent now, I may still do so at any time in the future by notifying the agent listed above via: email, text message, or phone call to receive an acknowledgment that consent has been terminated.
I further understand that:
1. The information I provide to enter on my Marketplace enrollment and eligibility application is true to the best of my knowledge. However, the help my agent provides is based solely on the information I provide, and if the information provided is inaccurate or incomplete, my agent may not be able to Offer all the help available for my situation.
2. 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.
3. If I provide my contact information when signing this form, my general consent includes permission for the authorized agent to follow up with me about applying for or enrolling in coverage after my first meeting with them.
4. Once I have signed this authorization form, I can expect the authorized agent named on this form to assist me without asking me to sign another authorization form.