F2E - Consumer Eligibility Application Confirmation Form (2 English)

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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