Enrollment Consent Form:

I, , give my permission to 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 phone only for one or more of the following:

• Searching for an existing Marketplace application
• 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
• Providing ongoing account maintenance and enrollment assistance, as necessary
• Responding to inquiries from the Marketplace regarding my 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 Pll is kept private and safe when collecting, storing, and using my Pll 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 confirm that I have reviewed my completed application and that all information is accurate.

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 contacting my Agent or by revoking it through my HealthSherpa dashboard.

Primary Writing Agent

Agency

Primary Applicant