CONSUMER ELIGIBILITY APPLICATION CONFIRMATION FORM
I, {{client_name}}, or my authorized representative, hereby confirm that I have reviewed and confirmed the accuracy of the eligibility application information prior to its submission for coverage through the federally facilitated exchanges and state exchanges on the federal platform. I understand that this confirmation is a requirement set forth by the Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS).
Details of the confirmation:
Date the application information was reviewed: {{current_datetime}}
Consumer or authorized representative's name: {{client_name}}
I acknowledge that I have read and understood the certifications provided at the end of the eligibility application, and I confirm that the information provided in the application is accurate to the best of my knowledge.
I further acknowledge that the agent, {{agent_name}}, has assisted me in completing the eligibility application and provided necessary support throughout the process.
By confirming the accuracy of the eligibility application, I understand that the information provided will be used for determining my eligibility for coverage through the federally facilitated exchanges and state exchanges on the federal platform.
Important: According to the requirements set by HHS and CMS, this confirmation and all related documentation must be retained for a minimum of 10 years. It should be available upon request in response to control, audit, and compliance activities.
Please retain a copy of this form for your records.
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