F1E - Consumer Consent Form (1 English)

CONSUMER CONSENT FORM

I, {{client_name}}, give my permission to {{agent_name}} to serve as the health insurance agent or broker for myself and my entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace. By consenting to this agreement, I authorize the above-mentioned Agent to view and use the confidential information provided by me in writing, electronically, or by telephone only for the purposes of one or more of the following: 

1. Searching for an existing Marketplace application;

2. Completing 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 for Marketplace premiums;

3. Providing ongoing account maintenance and enrollment assistance, as necessary; or

4. 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 purposes 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 in writing or by contacting them directly. The agent will provide further instructions on the steps required to rescind consent.

Name of Primary Writing Agent: {{agent_name}}

Agent National Producer Number: {{agent_npn}}

Phone Number: {{agent_phone}}

Email Address: {{agent_email}}

Name of Primary Household Contact and/or Authorized Representative: {{client_name}}

Phone Number: {{client_phone}}

Email Address: {{client_email}}

Date: {{current_datetime}}

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Privacy Notice: The information contained in this document is confidential and intended solely for the use of the person or entity to whom it is addressed. This document may contain material privileged or protected from disclosure under applicable law. If you are not the intended recipient or the person responsible for delivering to the intended recipient, please (1) note that any use, dissemination, forwarding, or copying of this document IS STRICTLY PROHIBITED; and (2) notify the sender immediately by telephone and destroy the document immediately.

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