Consumer Authorization Form

The Department of Health and Human Services requires licensed sales agents to obtain consumer consent prior to providing assistance to Marketplace consumers.  By signing this form, you acknowledge that the agent has informed you of the functions and responsibilities of agents in the Marketplace, and grant permission to the authorized licensed sales agent to conduct the following activities:

  • Conduct a search for the consumer application through the Marketplace
  • Assist with completing an eligibility application
  • Assist with plan selection and enrollment.
  • Assist with ongoing account/enrollment maintenance assistance, as necessary; or 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 purpose 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 purpose above.

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EXCEPTIONS OR LIMITATIONS TO CONSENT: I understand that I can revoke, limit, or otherwise change the consent I provide through this form at any time.  If I do not make any limitation, exceptions, or changes to my consent now, I can still do so at any time in the future by notifying the above authorized agent via:  email, text, or phone call. I further understand that:

  1. The information I provide for entry on my Marketplace eligibility and enrollment application is true to the best of my knowledge. However, the help my agent provides is based only on the information I provide, and if the information given is inaccurate or incomplete my agent may not be able to offer all the help that is 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 purpose.
  3. If I give 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 into 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 help me without asking me to sign another authorization form.